Every finding on record at Rehabilitation and Healthcare Center of Tampa

Based on observation, record review and interview, the facility failed to provide social services supports for one resident (#6) of fourteen sampled residents.Findings included: On 04/20/2026 at 10:21 a.m., a telephone interview was conducted with Resident #6's family member. She stated (Resident #6) only received $30.00 per month.An interview conducted on 04/20/2026 at 1:40 p.m. with Resident #6. He was observed in bed. He stated he had no money coming to the facility.On 04/21/2026 at 2:26 p.m. an interview was conducted with the Social Services Director (SSD). When asked if she had received any complaints regarding Resident #6, she stated she had not. The SSD stated for Resident #6, she was not sure whether a complaint had been received from the resident. She said she had not gone and spoke with him.On 04/21/2026 at 2:35 p.m., Resident #6 was re-interviewed. When asked about his income, he stated before he came to the facility, he was receiving $800.00 per month. He said, then the check from social security was reduced to $30.00. He stated the $30.00 does not come to him here at the facility. He stated there were no additional monies coming here. He said, I have been here two years, and no money. I asked them, and they told me there were no additional monies.A review of Resident #6's clinical chart, the admission record, documented an admission of 06/2024. His medical diagnosis list included: Need for assistance with personal care, spinal stenosis- cervical region, and chronic kidney disease.A review of a Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental status (BIMS) score of 15 which indicated the resident was cognitively intact.On 04/20/2026 at 4:46 p.m., an interview was conducted with the Business Office Manager (BOM). She confirmed Resident #6 was a Supplemental Security Income (SSI) recipient, and his SSI income was $30.00 per month. She confirmed Resident #6 should receive a supplement check (Personal Needs Allowance (PNA) of $130.00 from the state through the Department of Children and Families (DCF). She stated since returning to her position in 03/2026, she became aware Resident #6 was not in receipt of the PNA from the state. She stated the issue had been ongoing. She stated she had reached out to the facility's Medicaid Liaison to provide assistance with resolving the issue with DCF. She stated she does not reach out herself to DCF, that was what the Medicaid Liaison was for. On 04/21/2026 at 2:10 p.m., the BOM was re-interviewed with the Nursing Home Administrator Assistant (NHAA) present. The BOM provided business office notes for Resident #6, the last entry on the notes was 09/24/2025. Review of the business office notes revealed an entry, dated 09/23/2025, documented Resident #6's Institutional Medicaid coverage had been authorized on 09/23/2025 with an effective date of 08/2024. There was no note present that would indicate an inquiry had been made by the facility to address Resident #6's personal needs allowance of $130.00. On 04/21/2026 at 2:47 p.m., the BOM and NHAA were re-interviewed. She stated she had spoken with Resident #6 back in May 2025. She said the resident was concerned about why his SSI check had been reduced to $30.00. The BOM said the meeting discussion was held with the family member, the Nursing Home Administrator (NHA), the resident and me (BOM) by phone. She stated she had not documented the call. She confirmed the resident should get a supplemental check from the state, in the amount of $130.00 to make a total of $160.00 for his personal needs. The BOM stated she had reached out to the Medicaid Liaison on 03/06/2026 regarding Resident #6. The BOM said she had received a phone contact number from the Medicaid Liaison for a contact person at DCF. She said she had called the phone number, and the person answering the phone, (DCF representative #A), had told her she had retired, but had provided another name and phone number for the inquiry. A request for documentation of the correspondence and any further documentation for efforts to resolve the issue was made by this surveyor. On 04/21/2026 at approximately 4:30 p.m., the BOM and NHAA, provided a copy of an e-mail, dated 11/11/2025, the e-mail was titled Reinstating the 130.00 state income, addressed to (DCF Representative #A). The e-mail, documented: Are you able to assist with getting a resident's $130.00 state check reinstated, or advise what steps I can take to get his income reinstated? The BOM also provided an e-mail, dated 03/06/2026, from the BOM to the Medicaid Liaison, which stated, When you have a moment, could you please submit another URL (Uniform Resource Locator) for the $130? The response, dated 03/06/2026, was the copy of the 11/11/2025 e-mail (documented above). No further information was provided.On 04/21/2026 at approximately 4:35 p.m., this surveyor called the phone number listed on the 11/11/2025 e-mail, (DCF Representative #A) answered the phone. She stated she had retired from her position, the phone number on the document was a personal phone number. She stated, when she received any phone calls inquiring about the PNA checks, she would provide the phone number to her former supervisor and phone number. She stated there was a new specialist in the position to handle PNA inquiries. She said it would be an easy fix in the system and the PNA could be issued.The facility did not provide a policy/procedure for social services expectations.

Based on observation, record review and interview, the facility failed to ensure residents on two of three floors (2nd and 3rd floors) had an environment free from heavy foul and offensive odors during four of four days observed (3/30/25, 3/31/25, 4/1/25, and 4/2/25). It was found heavy odors emitted from two of thirty-four sampled residents (#163 and #80) and their rooms. Findings included: On 3/30/2025 at 9:58 a.m., the elevator doors opened on the second floor and there was immediately a heavy foul urine and offensive odor. After walking past the unit station and to Resident #163's room, it was observed the room door was closed. After knocking on the door and opening it, a very heavy foul urine and offensive odor emitted from this room. The odor was overpowering and leached throughout out areas to include the activity/dining room, hall near the shower room, the nurse station and down both halls approximately thirty feet away from Resident #163's room. Upon entering Resident #163's room, she was observed lying in bed on her side and over the bed linen. The bed and floor were observed dry and free from incontinence episodes. Resident #163 was also observed receiving nourishment via a tube feeding system. Resident #163 was observed with her eyes open but with cognitive deficits preventing her from being interviewed. The room and bathroom revealed no incontinent episodes, but the room emitted a heavy foul odor. Once the room door was opened to leave, there were various staff who passed by the room and indicated by putting their hands on their mouths and saying what is that smell. The staff members just walked by and did not stop to check on Resident #163. The same areas observed on the second floor were found with the same very heavy urine and offensive odors during the entire 7:00 a.m. - 3:00 p.m. shifts on 3/30/2025, 3/31/2025, 4/1/2025, and 4/2/2025. The heavy odors were also observed on the second floor upon shift change from 11:00 p.m.- 7:00 a.m. through to the 7:00 a.m.-3:00 p.m. shift during the same days listed. On 4/1/2025 at 7:56 a.m., Staff C, Housekeeper was observed to go in Resident #163's room to clean. She confirmed she cleaned the room every day and confirmed the room had a very bad odor. She revealed she cleaned the floors, walls, furniture, bathroom, equipment and the room still smelled. She confirmed the smell occurred in this room for more than a week to her knowledge. Staff C said she reported to staff and believed the nurse was aware. Staff C was observed to clean the room to include emptying the trash cans in room and bathroom, sweeping the room and bathroom, dry mopping the floors in the room and bathroom, wiping down the dresser, over the bed table and other high touch surfaces, as well as wet mopping the room. The cleaning products could be smelled, but the foul odor overpowered the cleaning products. After about twenty minutes the foul odor overpowered the cleaning products completely. Review of Resident #163's medical record revealed she was admitted to the facility on [DATE] and readmitted from the hospital on 3/4/2025. Review of the diagnosis sheet revealed diagnoses to include but not limited to: Dementia, Urogenital implants, History of Urinary Tract Infections, and Neuromuscular Dysfunction of Bladder. Review of the Minimum Data Set (MDS) assessment, dated 3/6/2025 revealed; Cognition/Brief Interview Mental Status or BIMS score: not scored. The section revealed the resident had both a long term and short term memory problem and with severely impaired decision making skills; Activities of Daily Living (ADL) - Toileting hygiene = Dependent on staff, Shower/Bathing = Dependent on staff; Bowel and Bladder - Checked as use of Indwelling Catheter, Urinary Continence - not rated, Bowel - Always incontinent. On 4/1/2025 at 2:05 p.m., Staff B, second floor unit manager was interviewed related to Resident #163 and the odors emitting from her and her room. Staff B revealed she had just come back from leave on Monday 3/31/2025 and she noticed a heavy odor coming from the resident's room. She revealed the resident had an infection that was being treated , she utilized a catheter, and received all nourishment via tube feeding system. Staff B revealed Resident #163's family had not been involved much with care planning. Staff B indicated she monitored staff to check and change residents frequently and at least every two hours. She revealed the resident received bed baths and she was on Palliative care. Staff B confirmed Resident #163 was checked and changed every two hours or as needed and the room was cleaned, but she felt the odor was from the infection she had been treated for. On Sunday 3/30/2025 at 11:12 a.m., on the third floor, the hallway leading to the Resident #80's room was found with heavy offensive body odor. The odor could be smelled over thirty feet before getting to his room. Once Resident #80's room, the last room on the hall was approached, the door was observed opened. The odor was very strong and was emitting from his room. The resident was observed seated upright in his bed and dressed for the day. Resident #80 appeared unshaven, hair unkempt, and the body odor was very strong emitting from him. An attempt to interview Resident #80 revealed he did not want to be bothered and just stated, I'm fine. He was asked about the heavy odor in the room but he did not answer. The heavy body odor emitted from the resident and his room through the third floor hall, approximately thirty feet down from his room during at least the entire 7-3 shift on days 3/30/2025, 3/31/2025, 4/1/2025, and 4/2/2025. Also, the odor could be found during shift change from the 11:00 p.m.-7:00 a.m. shift through to the 7:00 a.m.-3:00 p.m. shift. During many observations during the timeframes listed, there were staff and residents who were observed asking each other where the body odor was coming from. Review of Resident #80's medical record revealed he was admitted to the facility on [DATE] and readmitted from the hospital on 6/15/2022. Review of the diagnosis sheet revealed diagnoses to include but not limited to: Dementia, Mood disorder, and Major Depression. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed; Cognition/Brief Interview Mental Stats or BIMS score - 9 of 15, which indicated moderate cognitive impairment; Behaviors - none documented as exhibited during assessment timeframe; Mood - Feeling down 12 - 14 days of assessment period; no other mood indicators; (ADL - TOILETING = Independent, SHOWER/BATHING = Set up assistance, PERSONAL HYGIENE = Set up assistance. Review of the nurse progress notes dated from 1/29/2025 through to current 4/1/2025 revealed: - 3/31/2025 16:15 (4:15 p.m.) Progress note - Patient refused shower today x 3 attempts. Stated Please leave me alone; I just want to sleep. Will follow up with patient tomorrow. Review of the current care plans with a next review date 4/25/2025 revealed the following but not limited to: a. Preference/Choice: Resident has indicated the following preferences and/or has made the following choice regarding their health care: RESIDENT PREFERS TO DECLINE SHOWERS AT TIMES. Also refuses staff to take laundry at times, with interventions in place to include: Inform resident of positive benefits of following plan of care/or recommendations, explain the potential negative outcomes of preferences/choices. b. ADL - Resident has a history of ADL self care performance Deficit, with interventions in place to include - PERSONAL HYGIENE = Set up, BATHING = Check nail length and trim and clean on bath day and as necessary, BATHING = Offer/provide with a sponge bath when not a scheduled bath day or unable to tolerate or accepts schedule bath, BATHING = The resident requires supervision. On 3/30/2025 at 3:38 p.m., an interview with Staff T, Licensed Practical Nurse (LPN) revealed she was aware of the body odor emitting from Resident #80's room and confirmed the odor pretty much smells up the entire hallway. She revealed Resident #80 refused showers most times and he did not want to change. She revealed he was difficult most times when it came to personal hygiene and showers. Staff T confirmed there had been other residents on the hallway who have complained about the odor, but she felt there was nothing they could do, because he had the right to decline showers and personal hygiene. Staff U, Registered Nurse (RN) was interviewed related to the heavy body odor coming from Resident #80's room. He revealed the resident continually refused showers and personal hygiene. He revealed management had spoken to him about not bathing, and so had the Medical Doctor. Staff U also confirmed Resident #80 was being seen by psychological services, but was unaware if he had been working with psych regarding behaviors of not wanting to bath and or change clothes. On 4/2/2025 at 11:59 a.m., an interview with Staff V, Housekeeping Director revealed she and her staff were aware of several rooms that had constant odors and she was able to explain housekeeping cleaning schedules and what type of cleaning was completed. She said she or her staff identified odors that did not go away and found the odor was emitting from the resident, she and her staff notified management staff and nurses on the floor of the issue. She confirmed currently and from at least Sunday on 3/30/2025, Residents #80 and #163's rooms had a very heavy foul odor. She provided verbal processes of what type of cleaners were used in resident rooms and revealed the rooms were cleaned, but understood the odor emitted from the rooms, out into the halls, and into other resident rooms. On 4/2/2025 at 1:00 p.m., during an interview with a resident group, which consisted of five interviewable residents who wished to be confidential interviews, all confirmed there were bad smells that don't go away on a couple of the floors. The residents had passed their concerns along to staff to include aides, nurses, managers; but felt nothing had been corrected. The residents felt the ongoing foul odors had been a problem for about a week. Two of the residents who were in the group meeting resided near Resident #80 and #163's room. On 4/2/2025 at 9:30 a.m. during an interview with Staff A, Assistant Director of Nursing (ADON), she confirmed she and her direct care staff to include Certified Nursing Aides (CNAs) and Nurses, had noticed the very heavy odors at and near Resident #163 and Resident #80 rooms. She revealed Resident #163 had been treated for an infection which had caused a heavy odor and staff routinely checked and changed her, and observed the catheter for proper placement and leaks. She revealed the odor was very overpowering and she believed after the resident had completed her regimen of antibiotics, the odor would dissipate. She had ensured housekeeping services went in the room for cleaning more frequently than other rooms. Staff A said Resident #80's room and hallway near his room had a very heavy body odor and she and her staff had tried to educate him on the risks of not bathing and also to ensure a homelike environment for all the other residents on the hallway. She said he refused baths and changing of his clothes and he had the right to refuse. She was working with the Director of Nursing and the Nursing Home Administrator to see what other interventions they could put in place to fix the odor situation. Review of the Physical Environment policy and procedure with an effective date August 2024 showed; A safe, clean, comfortable, and home-like environment is provided for each resident, allowing the use of personal belongings to the greatest extent possible. Sufficient space and equipment in dining, health services, recreation, and program areas are provided to enable staff to provide residents with needed services. All essential mechanical, electrical, and resident care equipment is maintained in a safe operating condition through the facility's Preventative Maintenance Program. The procedure section of this policy included but not limited to: 2 . Maintain sufficient space and equipment in dining, health services, recreation, and program areas. 4 . Assure resident care equipment is clean, properly stored, and identified. Review of the Housekeeping policy and procedure with an effective date April 2017 showed; The facility will monitor each facility's housekeeping program for operational efficiency, quality, effectiveness and budget control. Provide a clean, safe, pleasant and a functional environment for residents, staff and visitors. Each facility will assign one person for each department who is responsible for the planning and coordination of consistent, effective housekeeping program. The procedure section of the policy revealed: Housekeeping to include: 1. Cleaning schedule and procedures, 2. Product usage, 3. Daily job assignments, 4. Room condition check list, 5. Frequency schedules

Based on observation, interview, and record review, the facility failed to ensure 1. Call light cords and buttons were placed within reach while residents were in bed in five of ninety-six resident rooms, on two of three floors, (Rooms 214a, 216p, 234a, 302a 310a, and 310b, ; and 2. Did not ensure bathroom call light cords were free hanging and not tied to hand rails for resident bathrooms 220, 226, 228, 234, and 310, during three of four days observed (3/30/25, 3/31/25, 4/1/25). Findings included: During various tour observations on 3/30/2025 at 10:00 a.m., 1:30 p.m., 3:00 p.m.; 3/31/2025 at 9:30 a.m., 2:00 p.m.; and on 4/1/2025 at 10:30 a.m. the following was observed: 1. Resident room [ROOM NUMBER]a was observed with the resident lying in bed and with the call light button and cord out from reach, lying on the floor back behind the head of the bed. 2. Resident room [ROOM NUMBER]p was observed with the resident lying in bed and with the call light button and cord out from reach, lying on the floor back behind the head of the bed. 3. Resident room [ROOM NUMBER]a was observed with the resident lying in bed and with the call light button and cord out from reach, lying on the floor back behind the head of the bed. 4. Resident room [ROOM NUMBER]a was observed with the resident lying in bed and with the call light button and cord out from reach, lying on the floor back behind the head of the bed. 5. Resident room [ROOM NUMBER]a was observed with the resident lying in bed and with the call light button and cord out from reach, lying on the floor back behind the head of the bed. 6. Resident room [ROOM NUMBER]b was observed with the resident lying in bed and with the call light button and cord out from reach, lying on the floor back behind the head of the bed. The resident room bathroom call lights in resident rooms 220, 226, 228, 234, 310 were observed wrapped several times or were tied to the metal wall hand rail. The call system could not be activated when pulling down on the cord. Photographic evidence obtained. On 4/1/2025 at 1:25 p.m., Certified Nursing Assistant (CNA) Staff G revealed that all staff when coming in the room were responsible for ensuring the call light was placed on the bed and within the resident's reach. On 4/1/2025 at 3:30 p.m., during interviews with Staff T, Licensed Practical Nurse (LPN) , and Staff U, Registered Nurse (RN) both revealed all residents had the right to have their call light buttons placed within their reach when they were in bed and when they were in chairs near their bed. Staff T and Staff U confirmed that all direct care staff should be monitoring frequently throughout the shift to ensure the call lights were within reach of the resident and if they found them out of reach, they were to reposition them. Staff U, as a floor supervisor, revealed he would make rounds throughout the shift as well to ensure the residents were properly positioned and with the call light placed within their reach. Staff T and Staff U confirmed they, as well as all staff in the building, had received and continued to receive inservicing/education related to the use and placement of call light cords/buttons. On 4/2/2025 at 9:30 a.m., an interview with the Assistant Director of Nursing revealed all staff were trained and inserviced on placing call lights within the resident's reach when the residents were in their room and in bed or in a chair. She confirmed it did not matter if the resident regularly used the call light or not, all residents had the right and were to have the call light button placed within their reach at all times. On 4/2/2025 at 11:00 a.m., an interview with the Nursing Home Administrator revealed the facility did not have a Call Light policy and procedure for review. He confirmed all residents should have call lights placed within their reach. Staff were to ensure the call lights were within the resident's reach each time they go in the room. 49227 50434 51097

Based on observation, record review, and interview, the facility failed to provide two of thirty-four sampled residents, (#107, and #36) with a homelike eating experience during two of three meals observed on 3/30/2025 and 3/31/2025. Findings included: On 3/30/2025 at 12:15 p.m., the third floor dining/activity room was observed during lunch service. It was observed with one long table and with seven residents seated at it in either wheelchairs or regular chairs. Resident #107, who was seated in his wheelchair at the end of the table, was observed without his meal. All the other six residents seated at the table had been served, set up with their meals, and were eating. However, Resident #107 was observed just watching the others eat, and without a meal tray of his own. Staff K, Certified Nursing Assistant (CNA) was the only staff member in the dining/activity room. She said she was assisting another resident with eating assistance and they had not got out Resident #107's meal yet. She said there were two other staff members who were in the room to serve and set up the meals for the other six residents, and then left the room to go serve meals to residents who were in their rooms. During the same observation, Resident #36 was seated in a reclining wheelchair away from the main table and she too had not received her lunch tray. Resident #36 was observed positioned in a manner to where she was facing and looking at other residents while they ate. An observation on 3/30/2025 at 1:10 p.m., revealed Staff G, CNA and Staff J, CNA came in the room and provided assistance with lunch to both Residents #107 and #36. Both residents were assisted with their meal at 1:13 p.m., fifty-eight minutes after all the others in the room had been served and set up with their meals. Most of the other residents who were seated at the same table and in the same room, were finished or almost finished with their meals just as Residents #107 and #36 began to eat. Residents #107 and #36 had cognitive deficits and were not able to answer questions related to their meal service. On 3/30/2025 at 1:15 p.m., interviews with Staff G and Staff J confirmed they first came in the dining/activity room to assist with tray pass to those who could eat on their own, and then left the room to assist with tray pass out on the unit to residents in their rooms. Staff G and Staff J also revealed they reported back to the dining room to assist with the meal for Residents #107 and #36. Staff G and Staff J confirmed the two residents waited a long time before they were assisted. On 3/31/2025 at 12:19 p.m., the third floor dining/activity room was observed for lunch service. Nine residents were in the room with three staff members in the room either seated next to residents, or assisting with coffee/hydration pass. On 3/31/2025 at 12:19 p.m., the first tray was brought in from a tray cart, which was located down a hallway, approximately twenty feet away. At 12:25 p.m. it was observed three of the eight residents seated at the long table, were served and set up with their meals. They all were able to eat without assistance. At 12:29 p.m. all eight residents seated at the same table had been served and set up with their meal. Resident #36 was seated in a wheelchair just three to four feet away from the table with the other residents and she was noted without a meal tray. At 12:33 p.m., Staff G brought in the meal tray for Resident #36 and began to set up the meal. Staff G sat next to the resident to cue her with eating. Resident #36 sat with no meal and meal assistance while all other in the room ate from 12:19 p.m. through to 12:33 p.m. Review of Resident #107's medical record revealed he was admitted to the facility on [DATE]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed; (Cognition/Brief Interview Mental Status or BIMS - no score. The cognition section revealed the resident had Short Term and Long Term memory problem and Severely Impaired Decision Making Skills); (ADL - EATING = Substantial/Maximal Assistance). Review of Resident #36's medical record revealed she was admitted to the facility on [DATE]. Review of the quarterly MDS assessment dated [DATE], revealed; (Cognition/BIMS score - 12 of 15); (ADL - EATING = Set Up or Cleaning assistance). During both observations of the resident while in the dining/activity room, revealed she was not able to answer questions related to her meal service. On 4/1/2025 at 2:00 p.m., an interview with Staff S, Registered Nurse Manager revealed she was not aware there were no supervisory staff in the third floor dining room for lunch on 3/30/2025 and 3/31/2025. She revealed all residents in the room should be served and set up with their meals around the same time and it was unacceptable that Residents #107 and #36 were served with their meals almost an hour after others were served. She revealed she, along with other managers, usually oversaw the dining service, but she was assisting with tray pass on the fourth floor. On 4/2/2025 at 11:00 a.m., the Nursing Home Administrator revealed the facility did not have a specific dining dignity policy and procedure for review. He revealed as part of dignity rights, all residents who sat in the same room and at the same table, should be served and set up generally at the same time, and being served almost an hour after others was unacceptable.

Based on observation, interview, and record review, the facility failed to ensure care plan interventions were implemented related to call light placement when residents were in bed for three (#163, #80, and #113) of thirty-four sampled residents. Finding included: 1. During observations on 3/30/2025 at 9:58 a.m., 3/31/2025 at 11:20 a.m., 12:25 p.m., 1:11 p.m., and on 4/1/2025 at 7:40 a.m., Resident #163 was seen in her room lying flat in bed and on top of the covers. She was noted looking up and at the wall with no affect. Resident #163 had cognitive impairment and was not able to answer questions related to her day, medical care and services. During each observed time, Resident #163 was found with the call light cord and button not on her bed, and not within reach. The call light was located on the floor back behind the head of the bed, and out of her reach. Photographic evidence obtained. On 4/1/2025 at 1:25 p.m., Staff G, Certified Nursing Assistant (CNA) confirmed the call light was on the floor and out of the resident's reach while she was in bed. Staff G revealed that all staff when coming in the room were responsible for ensuring the call light was placed on the bed and within the resident's reach. She said she did not believe Resident #163 had any behaviors of throwing or placing the call light button on the floor. Staff G was not aware the call light was on the floor and had been there for several days in the same position. Review of Resident #163's medical record revealed she was admitted to the facility on [DATE] and readmitted from the hospital on 3/4/2025. Review of the diagnosis sheet revealed diagnoses to include but not limited to: Dementia, Adult Failure to Thrive, Anxiety, and Mood disorder. Review of the current Minimum Data Set (MDS) assessment, dated 3/6/2025 revealed; Cognition/Brief Interview Mental Status or BIMS score: not scored. The section revealed the resident had both a long term and short term memory problem and with severely impaired decision making skills; Activities of Daily Living (ADL) - Dependent on staff for all Activities of Daily Living. Review of the current care plans with a next review date of 4/17/2025 showed a. Fall - The resident is at risk for falls or fall related injury because of: Gait/balance problems, Psychoactive drug use, with interventions in place to include but not limited to: Provide environmental adaptations: CALL LIGHT WITHIN REACH. 2. During tours on 3/30/2025 at 11:12 a.m., 1:00 p.m., 3/31/2025 at 8:20 a.m., and on 4/1/2025 at 9:50 a.m., Resident #80 was observed in his room and seated upright in bed, under the bed linen, and without a call light placed within his reach. When he was asked if he used the call light and if he knew where it was, he replied, I do use it to call for staff, and I don't' know where it is at. He said at times, the staff did not place it on his bed. His call light was observed on the floor, back and behind the head of the bed, and well out of his reach. Resident #80 said he could not reach it and there were times when he believed staff put it on the floor. Review of Resident #80's medical record revealed he was admitted at the facility on 2/4/2020 and readmitted from the hospital on 6/15/2022. Review of the diagnosis sheet revealed diagnoses to include but not limited to: Dementia, Mood disorder, and Major Depression. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] showed; Cognition/Brief Interview Mental Stats or BIMS score - 9 of 15, which indicated moderate cognitive impairment. Review of the care plans with a next review date of 4/25/2025 showed a. Falls - The resident is at Risk for falls or fall related injury because of: Deconditioning, Gait/Balance problems, Psychoactive drug use, with interventions in place to include but not limited to: Provide environmental adaptations: CALL LIGHT WITHIN REACH. On 4/1/2025 at 3:30 p.m. interviews with Staff T, Licensed Practical Nurse (LPN) , and Staff U, Registered Nurse (RN) both revealed all residents had the right to have their call light buttons placed within their reach when they were in bed and when they were in chairs near their bed. Staff T and U confirmed that all direct care staff should be monitoring frequently throughout the shift to ensure the call lights were within reach of the resident and if they found them out from reach, they were to reposition them. Staff U, as a floor supervisor, revealed he would make rounds throughout the shift as well to ensure the residents were properly positioned and with the call light placed within their reach. Staff T and Staff U confirmed they, as well as all staff in the building, had received and continued to receive inservicing/education related to the use and placement of call light cords/buttons. On 4/2/2025 at 9:30 a.m., an interview with the Assistant Director of Nursing revealed all staff were trained and inserviced on placing call lights within the resident's reach when the residents were in their room and in bed or in a chair. She confirmed it did not matter if the resident regularly used the call light or not, all residents had the right and were to have the call light button placed within their reach at all times. She was not aware the call light button was not placed within reach for Residents #163 and #80. 3. On 03/30/25 at 9:45 a.m. Resident #113 was observed laying in bed with his call light out of reach. Resident #113 stated he had a hard time getting his call light and it was always out of reach. Review of Resident #113 Admission Record revealed Resident #113 was admitted to the facility on [DATE] with diagnoses to include hemiplegia and need for assistance with personal care. Review of Resident #113 quarterly Minimum Data Set (MDS) dated [DATE] revealed in Section C, a Brief Interview for Mental Status (BIMS) score of 14 which indicated intact cognition. Review of Resident #113's active care plan revised on 01/03/2025, showed a focus area of ADL [Activities of daily living]:The resident has an ADL self care performance deficit weakness, impaired balance, recent hospitalization s and decline in function. Further review showed an Intervention of Call bell within reach while in room . A policy on Care Plans was requested; however, the facility was unable to provide. 51097

Based on observations, record reviews and interviews, the facility failed to provide treatment and care in accordance with professional standards of practice related to physician orders for pain parameters and administration of pain medications for one (Resident #147), and nebulizer treatments for one (Resident #132) of 34 residents reviewed for physician orders. Findings included: 1. On 3/30/25 at 9:52 a.m. during an interview and observation, Resident #132 said at the end of his of a breathing treatment he removed the nebulizer mask because staff took a long time to return. In the top drawer of Resident #132's bedside table were three plastic unopen ampules. Resident #132 said the ampules contained medication for his breathing treatment. Resident #132 twisted the cap off of one ampule and poured the clear liquid contents in the top opening of the connection between the mask and the medicine cup part of the nebulizer mask. Review of Resident #132's Minimum Data Set (MDS), dated [DATE], section c, showed the resident was independent with making decisions regarding tasks of daily living. Review of Resident #132's care plan showed a care plan focus for: the resident had oxygen therapy related to shortness of breath. Review of Resident #132's Medication Administration Record, dated March 2025 showed an order dated 3/18/25 for Ipratropium-Albuterol Solution, inhale 3 ml orally by nebulizer every six hours for cough for 7 days. Pre Evaluation: Describe Lung Sounds (CL-clear, D-diminished, R-rales, RH-rhonchi, W-wheezing). On 3/30/25 the documentation showed the administration of the medication did not occur. Resident #132's lung sounds are not documented. 3/25/25 was the last date administration of Ipratropium-Albuterol Solution was documented. During an interview on 4/1/25 at 9:50 a.m. Staff B, Registered Nurse (RN), Unit Manager (UM) said she needed to check the Resident #132's medical record to verify medication orders. She said Resident #132 needed Ipratropium-Albuterol Solution and she had changed the resident's oxygen supplies on 3/31/25. During an interview and record review on 4/1/25 at 5:15 p.m. with the Director of Nursing (DON), she was unable to find a current order for Resident #132 to receive Ipratropium-Albuterol Solution. The DON said her expectation was for residents to have a current order for each medication they received. Review of the facility's Medication Administration general guidelines, section 7.1 dated 09/18 showed the following: Policy- Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices .Procedures: Medication Administration 1. Medications are administered in accordance with [the] written orders of the prescriber. 2. During an observation on 03/3/2025 at 10:17 a.m., Resident #147 was observed lying in bed dressed in a hospital gown sleeping. Review of Resident #147's admission record revealed an admitted [DATE]. Resident #147 was admitted to the facility with diagnosis to include Muscle Wasting and Atrophy, Not Elsewhere Classified, Multiple Sites, Dysphagia, Oropharyngeal Phase, Other Neuromuscular Dysfunction Of Bladder, Acute Embolism And Thrombosis Of Unspecified Deep Veins Of Lower Extremity, Bilateral. Review of Resident #147's quarterly Minimum Data Set (MDS) dated [DATE] revealed, Section C. Cognitive Patterns, Brief Interview Mental Status (BIMS) 11 out of 15 which indicated Moderate cognitive impairment. Section N. Medications Antidepressant, Anticoagulant, Diuretic, and Opioid. Review of Resident #147's Orders revealed: 03/20/2025 Tramadol HCl Oral Tablet 50 MG (Tramadol HCl) *Controlled Drug* Give 50 mg by mouth every 6 hours as needed for Moderate to Severe Pain level 5 to 10 Review of Resident #147's Treatment Administration Record (TAR) for January, February and March 2025 revealed: Tramadol HCl Oral Tablet 50 MG (Tramadol HCl) .Severe Pain level 5 to 10 Pain level was recorded at 2 and medication was dispensed on 01/04/2025, 01/06/2025, 01/16/2025, 01/31/2025, 02/27/2025, 03/07/2025, 03/09/2025, and 03/12/2025. During an interview on 04/02/2025 at 12:44 p.m., Staff I, Licensed Practical Nurse (LPN) stated Resident #147 was prescribed Tramadol as needed for his neck and back pain. If his pain level was at a 1 or 2 she would give him Tylenol first. If that did not help, she would then give him Tramadol. During an interview on 04/02/2025 at 1:53 p.m., the Director of Nursing stated her expectation was for Nurses to follow physician orders. She stated she would not expect Pain medication to be given outside of the parameters on the order. There was no policy related to the concerns in this citation. 50434

Based on observation, record review, and interview, the facility failed to provide suctioning for one (Resident #70) with a Tracheostomy out of 34 residents sampled. Findings Included: During an observation on 03/30/2025 at 10:12 a.m., Resident #70 was observed sitting in bed dressed in a hospital gown and was observed to have a Tracheostomy with no suction. During an observation on 03/30/2025 at 12:15 p.m., the Risk Manager was observed bring a Suctioning machine onto the 3rd floor and putting into resident #70's room. During an observation on 03/30/2025 at 12:26 p.m., a suctioning machine was observed on the dresser in Resident #70's room. Review of Resident #70's admission record revealed a re-admitted [DATE] and initial admitted [DATE]. Resident #70 was admitted to the facility with diagnosis including Pneumonitis Due to Inhalation Of Food And Vomit, Chronic Respiratory Failure, Unspecified Whether With Hypoxia Or Hypercapnia, Encounter For Attention To Tracheostomy, Chronic Obstructive Pulmonary Disease, And Other Nonspecific Abnormal Finding Of Lung Field. Review of Resident #70's quarterly Minimum Data Set (MDS) dated [DATE] revealed, Section C. Cognitive Patterns, Brief Interview Mental Status (BIMS) of 14 out of 15 which indicated intact cognition. Review of section O. Special Treatments, Procedures and Programs, revealed Oxygen therapy, Suctioning, and Tracheostomy care. Review of Resident #70's Orders revealed: 03/29/2025 Trach: Suction Trach Post Record Amount of Secretions Characteristics of secretions: (Color, Odor, Viscosity) Lung Sounds, HR, Respirations and Tolerance as needed for Suction 03/29/2025 Maintain suction set up at bedside every shift and as needed. Review of Resident #70's Treatment Administration Record (TAR) for March 29th, 30th and April 2025 revealed: Trach: Suction Trach Post Record Amount of Secretions Characteristics of secretions: (Color, Odor, Viscosity) Lung Sounds, HR, Respirations and Tolerance as needed for Suction was blank. During an interview on 04/01/2025 at 5:49 p.m., Staff M, Registered Nurse (RN), stated Resident #70 secretions were white and sticky. She stated he had to be suctioned twice during her day shift on 04/01/2025. During an interview on 04/02/2025 at 10:58 a.m., the Risk Manager stated she brought up a suctioning machine to the 3rd flood on Sunday or Monday but could not remember if it was for Resident #70. She stated she did not normally work on the weekends and did not normally get equipment needed for newly admitted residents. The admitting nurse was responsible for getting all the supplies for the residents when they were admitted to the building. She stated they would only have the supplies ready for a resident who they knew were coming back to the facility and they did not know Resident #70 was coming back to the facility on [DATE]. During an interview on 04/02/2025 at 11:15 a.m., the Director of Nursing (DON) stated the machine had to be ordered because the one they had for Resident #70 had a broken knob. She stated they were not aware that Resident #70 was coming back on 03/29/2025 so they could not have ordered the supplies ahead of time. When the resident arrived, the nurse called the weekend supervisor and notified her the resident needed the suctioning machine. She reviewed the TAR for Resident #70 and stated the nurses should be documenting his secretions on the TAR. Review of the facilities undated policy titled Tracheal Bronchial Suctioning revealed: Purpose: Tracheal Bronchial suctioning is an effective way to maintain a clear airway and to aid in the removal of secretions for patients who are unable to clear their secretions when coughing. Procedure . 4. Gather the necessary equipment A. suction machine: I. Suction canister ii. Suction tubing Documentation:7. Color, consistency and amount of secretions. 8. Signature and credentials of personnel performing procedure.

Based on observation, interview, and record review, the facility did not ensure 1) availability of personal protective equipment (PPE) for four out of five bins on hallway 4 Long, 2) proper storage of respiratory equipment for one (Resident #132) of two residents, and 3) proper Contact Precautions were followed for one (Resident #155) of two residents on transmission-based precautions. Findings included: 1. On 3/30/2025 at 9:01 a.m., an observation was made of the 4 Long hallways of four out of five PPE bins missing gowns and/or gloves. Bin Five was located at the end of 4 Long hallways close to 4 Short hallway and had two gowns observed in the bottom drawer. On 3/30/2024 at 9:24 a.m., an observation was made in front of room [ROOM NUMBER] with a Contact Isolation Precaution sign on the front door with no PPE in the bin on the outside of the immediate room entrance. An unidentified Certified Nurse Assistant went down to the 4 Long hallways where bin 5 was and pulled the remainder of the two gowns there, offered one to the surveyor and placed the other gown in the bin in front of room [ROOM NUMBER]. On 3/30/2025 at 11: 45 a.m., an observation and interview was made of Staff S, Registered Nurse (RN) re- supplying the PPE bins on the 4 Long hallways. Staff S stated she was the weekday Unit Manager for the fourth floor and stated she was called into work today due to the survey. Staff S stated PPE supplies were located on the first-floor central supply. Staff S stated anyone could obtain supplies at anytime during day or night. Staff S stated there was no excuse for the lack of supplies observed on the 4 Long hallways' PPE bins. 2. On 3/30/25 at 9:52 a.m., during an interview and observation with Resident #132 his nebulizer treatment mask was lying uncovered on top of his bedside table. Resident #132 said he placed the nebulizer on top of his bedside table after the breathing treatment was completed, because it took a long time for staff to return. During an interview on 4/1/25 at 9:50 a.m., Staff B, Registered Nurse (RN), Unit Manager (UM) said she changed Resident #132's oxygen supplies on 3/31/25 and placed a new plastic storage bag. Staff B, RN, UM, agreed that when the nebulizer mask was not in use Resident #132 could not reach the storage bag. Staff B, RN, UM said the facility expected oxygen supplies to be placed in the storage bags when not in use. Review of the facility policy and procedure titled Oxygen Therapy dated effective November 2023 showed: Policy: Oxygen is provided to residents based on physician's orders to supplement oxygen as needed per disease process. 5. Oxygen Devices; a. Nasal cannula, . vi. Place in a labeled bag when not in use . 3. An observation was conducted on 04/01/25 at 1:00 p.m., Resident #155's room door had a sign posted above the room number to the right of the door entrance. The sign was laminated and bright yellow which showed: STOP CONTACT PRECAUTIONS EVERYONE MUST: Clean their hands, including before entering and when leaving the room. PROVIDERS AND STAFF MUST ALSO: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. Do not wear the same gown and gloves for the care of the care of more than one person. Use dedicated or disposable equipment. Clean and disinfect reusable equipment before use on another person. On 04/01/25 at 1:03 p.m., Staff P, Certified Nursing Assistant (CNA), was observed carrying a lunch tray and entered Resident #155's room. Staff P, CNA did not put on any Personal Protective Equipment (PPE). On 04/01/25 at 1:05 p.m., Staff P, CNA, was observed sitting in a chair with no PPE on while in the room of Resident #155, assisting the roommate with lunch. During an interview on 04/01/25 at 1:11 p.m., Staff O, Registered Nurse (RN) stated Resident #155 had a wound infection, currently being treated and requiring contact precautions. Staff O, RN stated for anyone who entered the room of Resident #155 a gown and gloves should be worn. Staff O, RN stated the signage on the door indicated to the staff what PPE and isolation precautions were to be followed. During an interview on 04/01/25 at 1:13 p.m., Staff P, CNA stated the signs on the door tell them what isolation precautions should be followed. Staff P, CNA confirmed the contact isolation sign on the outside of Resident #155's door. Staff P, CNA confirmed not wearing any PPE while in the room, due to not assisting Resident #155. Staff P, CNA stated they only needed to wear PPE when providing care for Resident #155, not entering the room. During an interview on 04/01/25 at 1:23 p.m., Staff Q, CNA stated they only needed to wear PPE when providing direct care to the resident, not upon entering the room. During an interview on 04/01/25 at 1:33 p.m., Staff R, CNA stated they only needed to wear PPE when providing direct care, not upon entering the room. During an interview on 04/02/25 at 11:46 a.m. with the Director of Nursing (DON) and Staff S, RN they stated the staff knew who was on isolation based on the signage outside of the door. The DON stated contact isolation required gown and gloves upon entering the room, regardless if care was being provided or not. Review of Resident #155's admission record revealed an admitted date of 08/21/24 and a readmitted [DATE] with diagnoses of Extended Spectrum Beta Lactamase (ESBL), pressure ulcer, Focal Traumatic Brain injury, and numerous other comorbidities. A review of Resident #155's physician orders reveals an order dated 02/19/25 for Contact Precautions ESBL on wound. A review of Resident #155's care plan revealed a Focus dated 2/18/25 INFECTION: the resident has an infection - ESBL. Reveals: Intervention/Tasks: dated 2/18/25 TYPE OF ISOLATION REQUIRED: Contact Precautions. Review of the facility policy and procedure titled Isolation Precautions - Categories of Transmission - Based Infections dated effective October 2021 showed: Policy: Standard Precautions shall be used when caring for residents regardless of their suspected or confirmed infection status. Transmission-Based Precautions shall be used when caring for residents who are documented or suspected to have communicable diseases or infections that can be transmitted to others. Contact Precautions: In addition to Standard Precautions, implement Contact Precautions for residents known or suspected to be infected or colonized with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. a. Examples of infections requiring Contact Precautions include, but are not limited to: (1) Gastrointestinal, respiratory, skin, or wound infections or colonization with multi-drug resistant organisms (e.g., MRSA, VISA, VRSA, VRE); . c. Gloves and Handwashing (1) While caring for a resident, change gloves after having contact with infective material (for example, fecal material and wound drainage). (2) Remove gloves leaving the room and wash hands with an antimicrobial agent or a waterless antiseptic agent. (3) After removing gloves and washing hands, do not touch potentially contaminated environmental surfaces or items in the resident's room. d. Gown (1) In addition to wearing a gown as outlined under Standard Precautions, wear a gown (clean, non-sterile) for interactions that may involve contact with the resident or potentially contaminated items in the resident's environment. Remove the gown and perform hand hygiene before leaving the environment. (2) After removing gown, do not allow clothing to contact potentially contaminated surfaces. g. Signs - A sign will be used to alert staff and visitors of the implementation of transmission based. Precautions while respecting the resident's privacy. The sign will be placed on the Resident's door & should state Report to Nurse Before Entering Room - The Nurse will educate individuals on the precautions implemented. 48441 49227

Based on observation, interview, and record review, the facility failed to ensure a process was in place for smoking safety for three (#8, #29, #164) out of 19 residents sampled. Findings Included: 1. During an interview on 10/28/2024 at 10:00 a.m., Resident #8 was observed lying in bed dressed for the day. To the right of her bed was a bedside table with a green and white box of cigarettes. Next to the box was a lighter. Resident #8 stated she was a smoker but only smoked occasionally when she was having a bad day. She stated she usually signed out at the front desk and went in front of the building to smoke. She stated she did not use the facilities smoking section because the smoking area was disgusting and the times available were not convenient for her. She stated, no one cleans the smoking area, and it smells out there. She stated she bought cigarettes from the store in front of the building and two packs last her up to six months. She stated all of the other residents in the facility knew they could come and see her, and she would give them a few cigarettes. She stated she had even bought lighters for other residents in the building. She stated she kept her smoking materials with her in her room. The facility provided a Smoker List upon request during the Entrance Conference conducted on 10/28/2024. Of the residents named on this list, Resident #8's name did not appear on the list of active smokers in the facility. Resident #8 was admitted to the facility on [DATE]. An Admission Minimum Data Set (MDS) was done on 09/17/2024. This MDS documented Resident #8 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. 2. During an observation on 10/31/2024 at 10:10 a.m., Resident #29 was observed sitting in her wheelchair dressed for the day and clean in appearance. Resident #29 was observed with a green lighter, while waiting for the aide to let her into the smoking patio. On 10/31/2024 at 2:00 p.m., a second observation of Resident #29 was attempted during the scheduled smoking time and no residents or staff were on the smoking patio. Resident #29 was readmitted to the facility on [DATE] and initial admission on 04/29/2022. An Admission Minimum Data Set (MDS) was done on 07/30/2024. This MDS documented Resident #29 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated she had intact cognition. 3. During an observation on 10/31/2024 at 10:12 a.m., Resident #164 was observed sitting in his wheelchair dressed for the day and clean in appearance. Resident #164 was observed with a lit cigarette in his hand on the smoking patio. On 10/31/2024 at 2:00 p.m., a second observation of Resident #164 was attempted during the scheduled smoking time and no residents or staff were in the smoking patio. Resident #164 was admitted to the facility on [DATE]. An Admission Minimum Data Set (MDS) was done on 10/03/2024. This MDS documented Resident #164 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated he had intact cognition. During an interview on 10/31/2024 at 9:45 a.m., with Staff K, Restorative Certified Nurse Assistant (RCNA), she stated she went out with residents for smoking at 10:00 a.m. and 2:30 p.m. After 3 p.m., it was the Certified Nurse Assistant (CNA) on the floor's responsibility to bring out any residents who smoke. She stated she and the medical records custodian go out with the residents at 2:30 p.m. She stated the medical records custodian was also a RCNA. She stated at this time they did not require a smoking apron for any residents. She stated they had a book with the resident's picture, and it told her if the resident needed an apron while smoking. There was also a log where she could include counts of how many cigarettes the residents' smoked and how many was left in their pack. Each pack of cigarettes was labeled with the resident's names, so she knew who belonged to who. She was not sure of the process for assessing the residents to know if they required smoking aprons or any other safety items. She stated that when residents first came into the facility, they came to the smoking section and then tend to not come after being in the facility for a while. She stated I think they quit smoking so that was why they no longer came to the smoking section. She stated it was usually the same three residents that came out during the smoking sessions During an interview on 10/31/2024 at 10:10 a.m., Staff L, CNA stated she helped supervise the residents during smoking times. She stated she also did the transportation and helped the residents go to outside appointments. She stated the residents who were in the smoking area were residents who could not go out for leave of absence (LOA) because they were careless with their cigarettes, meaning they drop it, or they were flicking ashes on themselves. She was not sure how the residents were assessed for needing supervision during smoking. She stated residents could not keep their smoking materials, so they kept them in a lock box and provided them with a lighter when they were outside. She stated the residents who signed out for Leave of Absence (LOA) got their smoking materials from the receptionist. During an interview on 10/31/2024 at 10:15 a.m. with Staff M, Receptionist, she stated residents came to her to sign out for LOA. She had a list she looked at to see who was allowed to sign out LOA. She then documented on the resident's sign out sheets of what time they signed out and would document when they signed back in. She stated if they had cigarettes in the lock box, she would provide them to them and they were supposed to turn them back in when they came back. She stated she took the smoking materials back from residents unless she was unaware that they had smoking materials. She was not able to find the lockbox where the residents smoking materials were kept at the time of the interview and stated they must have it on the smoking patio. During an interview on 10/31/2024 at 1:55 p.m., Staff G, Registered Nurse (RN), stated when new residents arrive, an admission assessment was completed. The facility protocols were explained to the residents including the smoking policy. An inventory of the residents' belongings were done with the CNA's and if the residents' said they were a smoker they let the residents' know their smoking materials would be in the lock box. She stated there was part of their admission assessment that had a spot where they answered if the resident was a smoker and when they mark yes it allowed them to answer more questions about the resident. She reviewed an admission assessment for Resident #24 was not able to locate the document she was referring to. During an interview on 10/31/2024 at 2:05 p.m., Staff N, RN, stated when a new admission came in, they get information about the resident. When the resident arrived, you complete the head-to-toe assessment, every system. If the resident was a current smoker, residents signed the education sheet, and they answered the smoking questions under the admission assessment. Staff N reviewed the electronic medical record for Resident #8 and located the question on the initial assessment where it asked if the resident was a smoker and indicated he would mark yes instead of no in that section, and it would prompt him to answer more questions about the resident. During an interview on 10/31/2024 at 2:30 p.m., the Director of Nursing (DON), stated when residents were admitted to the facility, they completed admission assessments, vital signs, and they asked questions to confirm how alert and oriented the resident was. The next day the Interdisciplinary Team (IDT) confirmed the residents' diagnosis and looked at antibiotics. On admission they asked if the resident had cigarettes or lighters, and they took them and put them in the lock box. She stated when residents first arrived, she watched the residents during their first smoking session and assessed the resident at that time and watched if the residents flicks their cigarette without getting ashes on them. She stated if a resident got ashes on them then that would indicate the resident needed an apron. She stated she educated staff before they could supervise residents during smoking times. She stated that she did not document this information anywhere. She stated she visited the smoking area to confirm residents were safe and that the aids were out there to supervise residents during smoking times. She stated she did not document these observations anywhere. She stated when the nurses did the assessment, they asked questions to determine if the resident was safe to smoke. She stated the nurses did not observe the residents smoking. She stated the facility did not have a smoking assessment and all they had was the form (resident family and visitor smoking safety education and acknowledgement) for residents to sign. She stated residents who smoked were care planned for smoking. She stated they did have residents who signed out LOA to go smoke. She stated residents that signed out LOA she could not control. She stated If staff observed a resident with a lighter or any other smoking materials it should be removed from the resident and added to the lock box. She stated residents should not be in possession of any smoking materials while in the building. On 10/30/2024 at 4:45 p.m., the (DON) was asked for Resident #8 and Resident #24's smoking assessments. The DON provided the surveyor a form labeled Resident family and visitor smoking safety education and acknowledgement and stated this was the facilities smoking assessment. Review of the Resident family and visitor smoking safety education and acknowledgement form revealed: State law prohibits smoking within the facility. It is the facility policy that smoking be directly supervised by staff members. This is to protect both the individual smoking and the entire resident population and staff. The facility has established appropriate smoking areas and smoking times that while not interfere with the care of other residents. Guidelines: 1. Smoking or tobacco material should be labeled with the resident's name and will be maintained in a secure location. Residents may not keep any smoking or tobacco materials in their room, or on their person, to include but may not be limited to lighters matches cigarettes pipes cigars E cigarettes or any other smoking materials. Facility staff will provide materials and assist each resident as needed during the posted smoking times in the designated area. 5. Residents families or visitors should not provide assistance with or distribute smoking material to any residents wishing to smoke. 6. Staff will ensure the availability of stop and watch tools or report changes and condition to nursing personnel. Review of the facility's policy titled Smoking/Tobacco Use dated August 2024 revealed: Policy The facility permits smoking and the use of tobacco products in accordance with state specific regulations. Each facility will identify specific, well-ventilated areas and designate the area(s) as approved smoking area(s). Smoking will not be permitted in any other location(s) Suspicion of non-compliance If necessary, and with resident consent or physician order in case of safety concerns, physical inspection of resident/storage areas will be performed by staff, including following contact with visitors who may be suspected of providing the resident with smoking materials and or associated articles. Smoking restrictions will not be assessed against residents for the convenience of the staff, but for the safety and well-being of the residents, staff and visitors. The smoking agreement will be provided to the resident slash resident representative to review and resign. Procedure: 1. The NHA and facility interdisciplinary team will determine the needs of the residents and established smoking times that will not interfere with the care and services of non-smoking facility residence . 2. Initiate and complete an admission data collection and initial plan of care or quarterly or as needed (PRN) data collection form if the resident requests smoking privileges. 3. Explain the smoking policy and request the resident or resident representative signed the smoking safety policy. A. File the signed original acknowledgement in the financial file B. Provide a copy to the resident or resident representative C. Place a copy of the resident medical record 4. Smoking/tobacco materials should be labeled with a resident's name and maintained in a secure location. Residents may not keep combustible smoking materials in their room. Residents are not to retain lighters, matches, cigarettes, e-cigarettes, ignitable tobacco products, or other smoking materials in their personal possession. Smoking Safety 1. Obtain the resident smoking material from the designated secure area. 9. Return the smoking supplies to the designated secure area. Education Guidance Residents/Resident Representatives 1. Residents that smoke, or their representatives, are provided with the smoking safety outline for signature. 2. Smoking materials are secured by staff for safekeeping. 3. Residents leaving independently for a leave of absence will return smoking materials and any new items to nursing staff upon return. 4. Family members or friends bringing in smoking materials will give such items to staff for safe storage.

Based on observation, record review, and interviews, the facility failed to ensure a accurate comprehensive care plan for one (#141) of eight sampled residents. Findings included: On 10/29/24 at 9:15 AM observed Resident #141 was not in room. The housekeeper in the room emptying trash can stated he already left for dialysis, referencing Resident #141. Observed white cup half filled with clear liquid with straw in cup, marked with 10/29/24. Review of resident #141 medical record showed an initial admission to facility on 08/20/2024 and readmission on 08/31/2024 with diagnoses including acute respiratory failure, and end stage renal disease. Review of physician orders revealed: - Enhanced Barrier Precautions: C-Auris, Dialysis Catheter and wounds. - Resident to have Dialysis on days: T TH S [name of dialysis center]. Catheter site: right subclavian, Bag meal/snack to go with resident to Dialysis yes or No:yes, Fluid Restriction yes or No:Yes. - 1200 cc Fluid Restriction- Dietary to give 900 cc nursing to give up to 300 cc/24 7-3(120 cc) 3-11(120 cc),11-7(60 cc). Minimum Data Set (MDS) dated [DATE] revealed: - Section C showed a brief interview of mental status score of 9 indicating mild cognitive impairment - Section O part J1 Dialysis marked yes. Part O1 IV Access marked yes. Review of Care Plan dated 08/20/24 revealed: - A focus of HEMODIALYSIS: The resident has renal failure and is on Hemodialysis Date Initiated: 08/20/2024. With an intervention Resident to have Dialysis on days: T TH S [name of dialysis center]. Bag meal/snack to go with resident to Dialysis yes or No: yes. Fluid Restriction yes or No: no. Date Initiated: 08/21/2024 Revision on: 10/21/2024 Dialysis Catheter Site- Observe for Signs and Symptoms of Bleeding. Date Initiated: 08/20/2024. - A focus of DISCHARGE PLANNING: The resident wishes/or Responsible Party wishes to:[ MISSING LOCATION] Date Initiated: 08/20/2024. With interventions including Discuss with resident/family/representative discharge planning process Date Initiated: 08/20/2024 RMGMT, and Referral to Local Contact Agency prn Date Initiated: 08/20/2024. With a goal of Safely Discharge to a lower level of care (Home, Home with HHA, ALF, ILF, other): Date Initiated: 08/20/2024 Revision on: 09/16/2024 Target Date: 12/05/2024. An interview was conducted on 10/30/24 at 12:40 PM with Resident #141. He stated he would like to discharge to a facility in [name of city], Florida, closer to his girlfriend to minimize her travel time and be able to see her more often. He stated he had told staff but unable to recall names of who he told. An interview conducted on 10/31/24 at 9:50 AM with Staff B, MDS coordinator. She stated she oversaw all the residents' care plans. She stated she created and updated the care plans as necessary. She stated a dialysis care plan would include the appointment time, dialysis center location, contact information for the dialysis center. She stated if a dialysis resident had a physician order for fluid restriction it would need to be reflected in the hemodialysis section of the care plan. She stated Resident #141's hemodialysis section of the care plan was incorrect as fluid restriction was marked no and should have been marked yes as Resident #141 had a physician order in place for fluid restriction. She stated his care plan needed to be corrected. An interview was conducted with Staff A, Social Services Director (SSD) on 10/30/24 at 10:00 AM. She stated discharge planning was discussed with the resident and or the resident representative at admission, during quarterly care plan meetings and as needed, or per resident/resident representative request. A Psychosocial history and Assessment evaluation was completed at admission and readmission for each resident. She stated the discharge location should be listed in the evaluation and in the care plan. She stated the care plan would be updated if the discharge location changed. She stated the discharge planning section of Resident #141 care plan was incomplete as it did not state his desired discharge location. She stated it needed to be corrected, and Resident #141's discharge location should be added to his care plan. A review of the facility policy titled Care Plan-Interdisciplinary Plan of Care from Interim to Meeting with effective date February 2024. It revealed in section Policy: 1. Managing risk factors to the extent possible or indicating the limits of such interventions. 2. Part I Social Services showed that discharge planning is to be discussed as part care plan process.

49497 Based on observation, record review, and interviews, the facility did not ensure accuracy of Preadmission Screening and Resident Review (PASRR) for two (#67 and #75) of 16 sampled residents. Findings include: 1. Review of Resident #67's medical record showed an initial admission to facility on 09/22/2022 and readmission on 02/26/2024 with diagnoses including unspecified dementia, other specified depressive episodes, schizophrenia and unspecified psychosis. Review of care plan dated 02/27/24 revealed: - A focus of BEHAVIORAL: The resident has been noted with the following behaviors: throwing things at staff, refusing care and services at times, combative at times, noncompliant with safety suggestions, refuses weights Date Initiated: 03/12/2024 Revision on: 05/29/2024. With interventions including Report missed or refused medication to physician (Missed doses can lead to an acute event & should be reported to the physician) Date Initiated: 03/12/2024 Observe/document for side effects and effectiveness. Date Initiated: 03/12/2024. - A focus of PSYCHOTROPIC MED: The resident uses psychotropic medications r/t Anticonvulsant to manage: Seizures. Date Initiated: 02/27/2024 Revision on: 02/27/2024. With interventions including Obtain and review lab/diagnostic work as ordered. Report results to MD and follow up as indicated. Date Initiated: 02/27/2024, Psychotropic Side Effects Monitoring: Agitation, Blurred Vision, Cardiac or Blood Abnormalities, Confusion, Constipation, Dry Mouth, Difficulty Urinating, Disturbed Gait, Drooling, Drowsiness, Headache, Hypotension, Involuntary movement of mouth, tongue, trunk or extremities, N&V, Pacing, Seizure Activity, Stiffness of Neck, Sore Throat, Tremors, Rashes Date Initiated: 02/27/2024. Administer medications as ordered. Observe/document for side effects and effectiveness. Date Initiated: 02/27/2024, and Psychiatry Services per order\PRN\protocol Date Initiated: 02/27/2024. Review of Minimum Data Set, dated dated dated [DATE] revealed: - Section C brief interview for mental status (BIMS) score of 13 indicating no cognitive impairment. - Section I marked yes for Non-Alzheimer's Dementia, Depression, Psychotic Disorder, and Schizophrenia. - Section N showed high risk drug class marked yes for antianxiety. Review of psych notes revealed resident seen by psych services on 10/29, 10/11, and 09/23. Psychology planned for continued monitoring. Review of Level I PASRR showed No marked for need of LEVEL II to be completed with patient having a secondary diagnosis of Dementia and 4 Mental Illness (MI) marked on page 2. An interview was conducted on 10/31/2024 at 10:00 AM with Staff A. She stated the process for PASRR, is when a resident came in from the hospital, she would review the PASRR for accuracy. She stated if it was not correct, she would complete a new PASRR. She stated she confirmed if a Level I PASRR needed to be submitted for a level II PASRR. She stated if a resident had a primary or secondary diagnosis of dementia, and a diagnosis of a mental illness she would submit for a Level II PASRR. She stated Resident #67 was not submitted for a Level II PASARR and that was incorrect. She stated Resident #67 should have had a Level II PASRR submitted as he had diagnoses of dementia and schizophrenia. 2. A review of Resident #75's Admission Record showed Resident #75 was admitted to the facility on [DATE] with diagnoses to include mood disorder due to known physiological condition, dementia, schizophrenia, convulsions, anxiety disorder, depressive disorder and encephalopathy. Review of Resident #75's Level I PASRR, dated 9/30/24, Section I, mental illness (MI) or suspected mental illness showed anxiety disorder, depressive disorder, schizophrenia and mood disorder due to known physiological condition. Review of Section II's instruction showed A level II PASRR evaluation must be completed if the individual has a primary or secondary diagnosis of dementia . Review of Section IV PASRR screen completion showed the level 2 PASRR evaluation is not required. An interview was conducted on 10/31/24 at 9:55 A.M. with the Social Services Director (SSD) and Social Services Assistant (SSA). The SSD said Resident #75 required a PASRR Level II evaluation. A review of the facility's policy and procedure titled, PASRR requirements level I and level II, February Effective 2021 showed, .The screening is reviewed by Admissions for suspicion of serious mental illness and intellectual disability to ensure appropriate placement in the least restrictive environment and to identify the need to provide applicants with needed specialized services . 2. Determine if a serious mental illness and our intellectual disability or a related condition exists while reviewing the PASRR form completed by the acute care facility (trigger for Level II completion.)

Based on observation, interview and record review, the facility did not ensure services provided/arranged by an individual had the skills, experience, knowledge and licensure to perform tasks for one resident (#142) out of eight residents observed. Findings included: On 10/28/2024 at 10:45 a.m., an observation and interview was conducted in Resident #142's room. Resident #142 was in a private room with thick yellow sputum on his hospital gown from his tracheostomy. A young man was sitting in a chair in the corner of Resident #142's room. The young man (Sitter #1) identified himself as a private sitter hired by the family. Sitter #1 stated he would assist the nursing staff with Resident #142's ADL (Activity of Daily Living) care during the day. On 10/29/2024 at 8:28 a.m., an observation and interview was conducted with Resident #142's private sitter (Sitter #2). Sitter #2 stated she was familiar with Resident #142 and stated she had been taking care of the resident since he had been at this facility. Sitter #2 stated she would do all ADL care for Resident #142 during her twelve-hour shift. Sitter #2 stated she would sign in the visitor log but because they knew her, she was rarely handed a visitor badge. Sitter #2 stated she would turn Resident #142 every two hours and would provide toileting when needed. Resident #2 stated, when she was on duty, she would never see another Certified Nursing Assistant (CNA) enter his room. Sitter #2 stated the nurses would come into his room to give him his medications and his feedings. On 10/29/2024 at 11:50 a.m., an observation and interview was conducted in Resident #142's room with Sitter #2. Resident #142 was clean shaven, and hair groomed and wet. Sitter #2 stated she had finished his full ADL care and provided lotion to his body. Sitter #2 stated the family had hired 24 hours /7 days a week sitter service. On 10/30/2024 at 9:43 a.m., an observation was made of Sitter #3 and Staff I, CNA providing incontinence care for Resident #142. Both were appropriately wearing PPE (personal protective equipment) during ADL care. On 10/30/2024 at 1:00 p.m., an observation and interview were conducted with Sitter #3, Sitter #3 was wearing a mask, gown, and gloves sitting in a chair in the corner of Resident #142's room. Sitter #3 stated she was a CNA. Sitter #3 stated she had performed ROM (range of motion) and turned Resident #142 every two hours. Sitter #3 stated Resident #142 still had a pressure area to his right ear in which she would roll up a washcloth to offset pressure on the right side of his face. Sitter #3 stated she would sign in at the front desk and get a visitor pass for the day. Sitter #3 stated she had asked the staff for mouth swabs today to clean his mouth and the staff provided them for her. Sitter #3 stated no other CNAs had come into Resident 142's room since she provided ADL care with Staff I, CNA this morning. Sitter #3 stated she placed zinc oxide on his bottom and groin due to chafing. A record review of Resident #142's Admission Record showed an initial admitted [DATE] with a readmitted [DATE]. A review of Resident #142's Minimal Data Set (MDS) dated [DATE] Section GG- Functional Abilities and Goals, GG0130-Self-care showed Resident #142 dependent for oral hygiene, toileting, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear and personal hygiene. Dependent is defined as - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or the assistance of two or more helpers is required for the resident to compete the activity. Section GG- Functional Abilities and Goals, GG0170-Mobility showed Resident #142 dependent for roll left to right. A review of Resident #142's care plan dated 7/18/2024 showed a focus area of Enhance Barrier Precautions related to wounds, gastrostomy tube, tracheostomy and Candida aureus with interventions to include but not limited to: Gloves and gowns to be worn when providing high touch resident care. A focus area of ADL: The resident has an ADL self-care performance deficit related to weakness, anemia, history of Transient Ischemic Attack (TIA), Chronic Kidney Disease (CKD), tracheostomy, diabetes mellitus type 2, dementia, seizure, cardiomegaly, cerebral infarction, and Alzheimer's. Interventions include but are not limited: Resident is total dependent upon staff for ADL's. Bed mobility dependent assistant of two to turn and/or reposition. Total toileting use dependent assist of two persons bathing the resident requires assist of two. On 10/30/2024 at 3:31 p.m., an interview was conducted with the Nursing Home Administrator (NHA), Director of Nursing, and the Assistant Nursing Home Administrator. The NHA stated he was unaware of the extent Resident #142's care was provided by the privately hired sitters. A review of the facility's policy titled Visitation Designated Essential Caregiver, effective November 2022 showed the following: as mentioned earlier in the policy, the essential caregiver or visitor will be screened, educated regarding infection control practices, personal protective equipment, remaining in the resident's room and/or minimal movement throughout the facility and any other protocols recommended by the department of health, CDC or other agency at the time of visitation when visiting residents were signs or symptoms of respiratory illness or infectious disease. The essential caregiver is not required to provide necessary care to the resident.

Based on observation, staff interview, and record review, the facility failed to provide an ongoing activity program that provided one on one activities as scheduled and met the individual interests and needs to enhance the quality of life for two (#154 and #472) of two sampled residents. Findings Included: During an interview on 10/28/24 at 11:00 A.M., Resident #154 said he preferred to stay in bed, he felt weak due to recent cancer treatments. He wanted to participate in activities but the facility staff had not offered or provided bedside activities. Review of Resident #154's admission record, showed admitted [DATE]. Review of Resident #154's order summary report active orders as of 10/28/24, showed monitor and record pain every shift, restorative nursing as needed, Tramadol 50 mg every 6 hours as needed for pain. Review of Resident #154's care plan focus on pain, initiated 7/1/24, showed resident has pain or a potential for pain related to chronic knee pain and other comorbidities [and] muscle spasms. The care plan goals included Resident #154 will participate in activities of choice. Care plan interventions to included 1) report to nurse any change in usual activity attendance patterns . 2) Invite, encourage, remind and escort to preferred activities . Review of care plan focus titled, activities, initiated 7/1/24 showed the resident requires staff assistant with involvement of activities .The interventions included encouraged to participate with activities of choice, provide the resident with materials for individual activities. Review of Resident #154's Documentation Survey Report V2, dated October 2024, did not show participation in group or individual activities throughout the month. Review of Resident #154's Activity Assessment, signed 7/5/24, showed Resident #154 preferred activities in the afternoon and required physical assistance to and from activities. Resident #154 preferences included one-to-one and in-room activities. The activities Resident #154 enjoyed included word puzzles, one-on-one daily chronicle social and listening to music. Resident #154 enjoyed participating in self-directed activities and activity supplies items chosen by the resident. Review of Resident #154's admission Minimum Data Set (MDS) dated [DATE], Section C, cognitive patterns showed a Brief Interview for Mental Status (BIMS) score 15/15, which indicated intact cognition. Section GG, Functional Abilities and Goals, showed Resident #154 mobility devices were a walker or wheelchair. Review of the facility activity calendar dated; November 2024 showed 3:00 P.M daily 1:1 room visits were scheduled. During an interview on 10/31/24 at 9:00 A.M., the Activities Director (AD) said, during one-to-one room visits staff read, sang, provided cross word puzzles and coloring books for the residents. The AD said now she had an assistant; they would split the one-to-one room activities assignment. The AD said one-on-one activities were not documented in the resident's medical record, a logbook is used. During an interview on 10/31/24 at 9:12 A.M., the AD provided the facility's Weekly Activity log. A review of the weekly activity log dates week of 10/28/24, section titled 3:00 P.M. Activity did not include Resident #154's name. In the section of the log titled extra added activities showed all residents receive one to one room visits while delivering weekly menu During an interview on 10/31/24 at 2:43 P.M. the Director of Nursing (DON) said she expected staff to assist residents with activities. It was important to have all residents involved in activities. 46498 During an observation on 10/29/2024 at 10:15 a.m. and 4:00 p.m., Resident # 472 was observed lying down in bed throughout the day without being provided activities. When she was asked questions, she was only able to speak in Creole. She was observed with her television on an English- speaking program all throughout the day During an observation 10/30/24 at 9:45 a.m., 2:00 p.m., and 4:00 p.m., Resident # 472 was observed lying down in bed throughout the day without being provided with activities. She was observed again with her television on an English-speaking program. Review of Resident # 472's Admission Record dated 10/31/2024, showed she was originally admitted on [DATE] with diagnoses to include but not limited to Other Cerebral Infarction Due to Occlusion or Stenosis of Small Artery, Need for Assistance with Personal Care and History of Falling. Review of Resident # 472's Minimum Data Set (MDS) dated [DATE], showed a Brief Interview Mental Status (BIMS) score of 10, which indicated moderate cognitive impairment. Review of Resident # 472's care plan focus for Activities revealed Resident # 472 required assistance with involvement of Activities related to may not staying for the entire activity. Cognitive deficits, Requires physical assistance to and from activities. Date Initiated: 10/25/2022, date revised: 8/16/2023. The goal of this care plan stated, Resident 472 will participate in activities of choice/ will participate in activities. Date initiated 10/25/2024, date revised on 7/15/2024, target Date 1/12/2025. The Intervention of this care plan stated, encourage to participate with activities of choice. Date initiated 10/25/2022 On 10/31/2024 at 9:00 am., an interview was conducted with the Activities Director. She stated that she did one to one room visits three times a week. During her room visits she discussed with residents about their activity preferences and provided them with puzzles or games of their choice. She stated if a resident spoke Spanish, she would get someone to assist with translating their questions to find out the resident's activity preference. If a resident spoke Creole, she would have to use a translator, but she had never had to experience working with a Creole speaking resident. She stated she was not even aware that the facility had a resident that spoke Creole. She stated she did not have a process in place to show that she conducted room visits and she had not looked at the resident's care plans to see if their activity intervention was being followed out. On 10/31/2024 at 11:00 a.m., an interview was conducted with Resident # 472 representative. He stated that his mom could only understand Creole and did not understand English or speak English. He stated he would like to see his mom out of her bed more and involved in activities in the facility. The staff had not called him about finding out what type of activities his mother was interested in participating in. On 10/31/2024 at 3:00 p.m., an interview was conducted with the Director of Nursing (DON). She stated her expectation was for all residents to participate in activities or at least be offered the opportunity to participate. If the resident refused to participate in an activity, it was their right, but they should still be offered the opportunity. The Activities Director should document the resident refusal and then follow up with the resident to see what we could do to get them involved in some type of activity. She stated she would work with the Activities Director to see what they could do for Resident # 472 because the resident spoke Creole. Review of the facility policy titled, Activities Overview, Effective dated October 2021 showed Policy: Activities Department employees will provide activities that include sensitivity and an understanding of each individual resident's needs and requirements including medical, emotional, spiritual, therapeutic, and recreational needs. The Activity Programs will reflect individual needs and provide/ promote the following: Stimulation or solace, physical, cognitive, and/or emotional health, enhancement, to the extent practicable, of each resident is physical and mental status, resident self-respect by providing activities that support self-expression, social and personal responsibility, and choice.

Based on observation, interview, and record review, the facility failed to provide emergency tracheostomy supplies for three residents (#142, #25, and #156) of three residents observed. Findings included: 1. On 10/28/2024 at 1:48 p.m., an observation and interview was conducted in Resident #142's room with Staff E, Registered Nurse/Unit Manager (RN/UM). Resident #142 did not have the same size and a smaller size tracheostomy set in his room. Staff H, RN/UM agreed resident did not have this equipment. A record review of Resident #142's Admission Record showed an initial admitted [DATE] with a readmitted [DATE]. Resident #142 has a diagnosis of chronic respiratory failure unspecified whether with hypoxia or hypercapnia and tracheostomy status. A review of Resident #142's Minimal Data Set (MDS) dated [DATE] Section O- Special Treatments, Procedures and Programs, area under Respiratory Treatments C1 -Oxygen therapy, D1-Suctioning and E1- Tracheostomy care was each checked off as present. A review of Resident #142's physician orders have an order dated 7/18/2024 to maintain ambu (resuscitation) bag at bedside and replacement trach of equal size and one size down maintained at bedside every sift for Preventative Measure. A review of Resident #142's care plan dated 7/18/2024 showed a focus area of Tracheostomy with interventions/tasks include but not limited to: Maintain ambu bag and replacement trach at bedside per order 2. On 10/30/2024 at 4:00 p.m., an observation and interview was conducted in Resident #25's room with Staff O, RN. Resident 's #25's humidifier bottle was dry and dated 10/27/24. Staff O, RN was unable to locate suction catheters in Resident #25's room. Oxygen was set at three liters per minute. Photographic evidence obtained. A review of Resident #25's Admission Record showed an admitted [DATE] with a diagnosis of chronic respiratory failure, unspecified whether with hypoxia or hypercapnia. A review of Resident #25's physician orders dated 7/29/2024 showed an order for humidified oxygen per trach continuously two liters every shift for shortness of breath. A review of Resident #25's care plan dated 7/27/2024 showed a focus area of Tracheostomy with interventions/tasks to include but not limited to: Give humidified oxygen as prescribed. 3. On 10/30/2024 at 4:10 p.m., an observation and interview was conducted in Resident #156's room with Staff P, RN. An observation was made of a dark pink, light red liquid 3/4 of the way full in the resident's suction canister. Staff O, RN stated the canister should be changed but was unable to locate a new canister in the resident's room. Staff O, RN stated he would go downstairs immediately to central supply on the first floor to obtain a new canister. Photographic evidence obtained. On 10/20/2024 at 4:20 p.m., an observation and interview was conducted with Staff H, RN/UM. Staff H, RN/UM stated Staff P, RN did not have to go downstairs to central supply and stated each floor had its own supply closet for respiratory supplies. In the supply closet, Staff H, RN/UM was unable to locate extra canisters for suction collection nor suction catheters. Staff H, RN/UM stated Staff O, RN was in here recently for suction catheters and must have removed them. A record review of Resident #156's Admission Record showed an initial admitted [DATE] with a readmitted [DATE]. Review of Admission Record showed Resident # 156 with a diagnosis of chronic respiratory failure unspecified whether with hypoxia or hypercapnia and tracheostomy status. A review of Resident #156's Minimal Data Set (MDS) dated [DATE] Section O- Special Treatments, Procedures and Programs, area under Respiratory Treatments C1 -Oxygen therapy, D1-Suctioning and E1- Tracheostomy care was each checked off as present. A review of Resident #156's physician orders dated 10/15/2024 showed the following orders: To change suction canister every 72 hours and /or when 3/4 full as needed. Trach suction: trach pre-record lung sounds, HR, and respirations as needed for suction as needed (prn) Trach suction: trach post record amount of secretions characteristic of secretions: (color, odor, viscosity) lung sounds, HR, respirations and tolerance as needed for suction prn. Acetylcysteine inhalation solution 10% four milliliters via trach four times a day for abnormal mucous secretions. 10/16/2024 Ipratropium-Albuterol solution 0.5-2.5 three milligrams /three milliliters via trach every six hours for shortness of breath. Pre-evaluation: describe lung sounds (Cl-clear, D-diminished, R-rales, Rh-rhonchi, W-wheezing). A review of Resident #156's care plan dated 10/14/2024 showed a focus area of Tracheostomy with interventions/tasks include but not limited to: Maintain ambu bag and replacement trach at bedside per order Give humidified oxygen as prescribed Suction as needed. On 10/31/2024 at 1:09 p.m., an interview was conducted with the Director of Nursing (DON). The DON was aware of findings and stated the concerns will be rectified. A review of the facility's policy titled, Ventilation effective date of December 2022 showed a policy statement: The nurse will perform an emergency tracheostomy tube change in the event that a tracheostomy tube becomes displace or dislodged. Equipment needed include the following but not limited to: Resuscitation bag Oxygen source Tracheostomy tubes-one the same size and one a size smaller Suction kit (water soluble lubricant, gloves). Suction machine A review of the facility's policy titled Tracheal bronchial suctioning no effective or revised date showed the following purpose statement: Tracheal bronchial suctioning is an effective way to maintain a clear airway and to aid in the removal of secretions for patients who are unable to clear their secretions when coughing. The indications for tracheal bronchial suctioning include: Accumulation of secretions in the airway Obstruction of the airway due to secretions Inability to swallow and Ventilation through an artificial airway with interference of normal clearance mechanism The Procedure for tracheal bronchial suctioning includes but not limited to: . 4. Gather the necessary equipment a. Suction machine: i. Suction canister ii. Suction tubing b. Suction catheter kit: i. Sterile gloves ii. APPROPRIATELY sized suction catheter (see clinical considerations) iii. Container for holding sterile water/saline.

50732 Based on record reviews and interviews, the facility failed to prevent falls/accidents resulting in an injury to one resident (#1) out of three residents sampled for falls. Resident #1 sustained a scalp hematoma and clavicle fracture with a transfer to a higher level of care. Findings included: Review of the Admission Record showed Resident #1 was originally admitted to the facility in 2017 and discharged to a local hospital on 07/16/2024. The Admission Record showed diagnoses to include: other sequelae following unspecified cerebrovascular disease, muscle wasting and atrophy, dementia, weakness, lack of coordination, and need for assistance with personal care. A review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #1 revealed a Brief Interview for Mental Status (BIMS) score of 3 showing severe cognitive impairment. The resident had no mood or behaviors identified, and no falls since the prior MDS assessment dated [DATE]. The resident required substantial/maximal assistance with rolling left and right, was always incontinent of bowel and bladder, and was dependent on a helper to perform all effort for toileting hygiene. A review of the comprehensive Care Plan initiated on 4/11/2018 with a goal revision date of 4/17/2024 showed: -Focus: The resident has impaired thought processes r/t Dementia. Interventions included: Explain care before providing it. Face the resident when speaking and make eye contact if possible. Provide orientation and validation. -Focus: The resident has an Activity of Daily Living (ADL) Self Care Performance Deficit as evidenced by: Cannot complete ADL tasks independently and safely, requires individualized interventions to maintain because of weakness, fatigue, impaired cognition, and fear of falling. -Interventions included: Bed Mobility: Assist of 2 to turn and/or reposition. TRANSFER: Total Mechanical Lift to chair of 2 assist. PERSONAL HYGIENE: Assist of 1. -Focus: Fall-The resident is at risk for falls or fall related injury because of cognitive and sensory factors: dementia, poor safety awareness, fearfulness, and medication side effects. -Interventions included: Provide environmental adaptations: low bed. A review of the Certified Nursing Assistant (CNA) Patient Care Kardex dated 07/27/2018 for Resident #1 showed: -Transferring: Total Mechanical Lift to chair of 2 assist -Bed Mobility: Assist of 2 to turn and/or reposition -Personal Hygiene: Assist of 1 A review of the Physical Therapist progress and Discharge Summary dated 7/16/2024 revealed Resident #1 did not meet the bed mobility goal to roll from side to side with minimum assist (1-25% assist) with 40% tactile and verbal instruction/cues in order to improve safety and independence with functional bed mobility tasks. The bed mobility status as of 7/16/24 was able to roll from side to side with moderate assist (26-75% assist) with 60% tactile and verbal instruction/cues. There was no documentation in the clinical record to show the resident independently rolled from side to side without staff assistance and no documentation showed the number of staff needed to assist with bed mobility or transfers had decreased from 2. A review of Nursing Notes and Progress notes for Resident #1 showed: -7/16/2024 8:00 pm Progress Note: During resident care the CNA rolled resident onto her side to provide pericare and repositioning. The resident rolled over before the CNA could stop her which resulted in the resident rolling out of the bed. Neuro checks done. within normal limits (WNL). Vital signs stable. Laceration noted to left temple and left forearm. Resident moves all extremities without difficulty. 911 called to transfer to ER for evaluation. A review of the medical transportation (ambulance) Patient Care Report dated 7/16/2024 signed by an Emergency Medical Technician (EMT) showed: -Medical Transportation received call at 7:50 pm on 07/16/2024 and arrived at the facility at 8:02 pm. -Resident #1 complained of head pain secondary to a fall. Resident #1 had rolled off their bed and hit their head on the wooden floor. -The assessment for Resident #1 showed a golf ball size hematoma to the left side of Resident #1's head with some controlled bleeding. The resident also had a skin tear on her left elbow that was already bandaged. A review of the Hospital Discharge Summary for Resident #1 dated 07/19/2024 showed a diagnoses list to include clavicular fracture, fall, ground-level fall, hyperkalemia, hyponatremia, and NSTEMI (non-segment [ST] elevated myocardial infarction) -Shoulder x-ray findings showed an acute, mildly displaced fracture of the left distal clavicle. -Computed Tomography Head (CTH) showed a moderate sized left frontal scalp hematoma. An interview with Staff A, CNA, on 08/19/2024 at 3:00 pm revealed she went to Resident #1's room to provide evening care on 7/16/2024. She saw the resident had a large bowel movement and she rolled the resident on her right side to clean her up. Staff A reported turning her head from the resident to call out for Staff C, CNA, to come into the room to help her clean the resident up. Staff A reported Staff C never came to the room. Staff A said when she turned her head, the resident rolled out of the bed onto the floor. She said she ran out of the room to get the nurse. She stated the resident had never done that with her before. Staff A said she went back into the room and other CNAs came into the room to help. She said they moved the furniture out of the way, and they were debating on whether or not to move the resident back to her bed. She said the nurse told them not to move the resident, so they did not. Staff A said she was sent home and did not return to work until the following Monday (7/22/24). She did not know what happened to the resident after she went to the hospital. The resident was not in the facility when she returned to work. An interview was conducted with Staff B, CNA on 08/19/2024 at 3:30 pm. Staff B said she was outside of Resident #1's room documenting on 7/16/2024 when the incident occurred. She was not taking care of the resident that night, but she said she had taken care of the resident several times before. She said she went to the room after the resident fell out of the bed and saw the resident on the floor with her head next to the cabinet. She asked the resident if she was ok, and the resident said yes. Staff B reported the bed was raised to the height to perform resident care. She said the nurse came in the room to help the resident, and Staff B, CNA left the room to continue documenting. Staff B, CNA said when she has taken care of the resident in the past, she always had another CNA help her if the resident needed to be cleaned up. She said you always need two people when this resident needs care. An interview was conducted with the Nursing Home Administrator (NHA) on 08/19/2024 at 4:00 pm. The Registered Nurse (RN) Risk Manager was in attendance, but did not answer any questions. The NHA said on 7/16/2024 he and the Risk Manager were notified by staff that Resident #1 had a fall during care. He said staff was interviewed immediately after the incident. He said when Staff A went to Resident #1's room to get her settled for bed, Staff A saw the resident had a large bowel movement, and Staff A decided to clean the resident up. The NHA said Staff A raised the bed to the ergonomic height to provide care to the resident. He said at first, Staff A thought she could take care of it herself and rolled the resident on her side and called out for help. Staff A needed more supplies. The NHA said Staff A could not remember if she turned her head from the resident or not when calling for help. He said Staff A was in shock over what happened. He stated the bed was moved out of the room to provide assistance to the resident after the fall. The NHA said the resident was reaching for her snacks on the bedside table and rolled out of the bed. He said the resident was always hungry, and the family brings her snacks. He said by the time Staff A turned around, the resident was on the floor. The NHA said other staff members told him Resident #1 could be quick. He said they called 911, and the resident was sent to the hospital to get checked out. He said they were informed by the hospital the resident's Computed Tomography (CT) scan was negative for a head injury. He said they did a reenactment of the incident with the staff who were involved. Staff A said to the NHA she can take care of the resident by herself when she needs to be changed, but since it was a large bowel movement she called for help. The NHA said that turning this resident on her side would be a one person assist because Staff A was performing hygiene care. The NHA also said since the resident was turned on her side, it could be considered a two person assist stating, It could be considered both ways. The NHA said after completing the investigation it was determined the incident was unsubstantiated for neglect. However, a review of a facility report dated 7/23/24 revealed Abuse, Neglect, Exploitation, and Misappropriation (ANEMI) education was completed for all staff on 7/22/24.

Based on observations, interviews, and record review, the facility failed to ensure a safe, clean, comfortable, and homelike environment for two patient floors (3rd and 4th) out of three patient floors in the facility. Findings included: During an observation of room [ROOM NUMBER] on 05/13/24 at 11:42 AM at the side of the resident bed located closest to the window, the flooring was noted to be lifting. (Photographic Evidence Obtained). A review of the facilities electronic maintenance system report for the past month revealed no concerns related to the floor lifting in room [ROOM NUMBER]. A review of the Concierge rounds report for the month of May 2024 revealed no concerns related to the floor lifting in room [ROOM NUMBER]. During an interview on 05/16/24 at 10:10 AM with the Nursing Home Administrator (NHA), he stated the facility utilizes a concierge rounds system and all concerns are documented on the rounds form. He stated if it is a serious concern it is placed on the electronic maintenance system and monitored for completion. He stated all concerns are discussed during the morning meetings, but he was unsure about the floor lifting in room [ROOM NUMBER]. An observation conducted on 5/13/2024 at 10:46 AM inside of room [ROOM NUMBER] revealed large portions of peeled laminate flooring next to bed B in the room. The flooring was observed unattached to the floor and was able to be freely moved while walking over it with small portions of the tile flooring underneath of the laminate visible. The wall behind bed B was observed to have several deep scratch marks with missing paint and visible debris on the floor below. An interview was conducted on 05/14/2024 at 1:23 PM with Staff H, Registered Nurse (RN), Unit Manager (UM) inside of room [ROOM NUMBER]. Staff H, RN UM stated any maintenance concerns are documented in the facility's electronic maintenance system or the concerns can be relayed directly to the maintenance staff by phone. Staff H, RN UM observed the flooring by the air conditioning unit in room [ROOM NUMBER] and the damaged wall behind bed B. Staff H, RN UM stated maintenance staff have been working on fixing concerns related to the flooring and paint in the resident rooms on the unit but was not sure if maintenance staff were aware of the concerns in room [ROOM NUMBER]. An observation conducted on 5/14/2024 at 1:35 PM inside of room [ROOM NUMBER] revealed visible moisture in front of the air conditioning unit near bed B. The flooring in front of the air conditioning unit was observed unattached to the floor and was able to be freely moved while walking over it. An observation was conducted on 5/16/2024 at 11:20 AM inside of room [ROOM NUMBER]. Staff M, Maintenance Assistant (MA) was observed inside of the room with a large vacuum in front of the air conditioning unit, which was removed from the wall. An interview was conducted with Staff M, MA following the observation, with assistance of a translation application. Staff M, MA stated the air conditioning unit inside of the room was leaking and he was in the room to repair the issue, which was brought to his attention today. Staff M, MA also stated if staff identify a maintenance concern within the facility, they can document the concern in the facility's electronic maintenance log, which is relayed to an application on his phone. Staff M, MA stated he was informed of the flooring concern in 409 today but did not have knowledge of the concern prior to 5/16/2024. An interview was conducted on 05/16/2024 at 1:04 PM with the facility's Director of Nursing (DON). The DON stated any environmental or maintenance concerns identified by staff should be relayed to the floor's Unit Manager, who documents the concern in the facility's electronic maintenance log. The DON also stated any concerns related to damage to the flooring, walls, or equipment should be addressed and reported. Photographic evidence obtained. An observation on 05/13/24 at 12:00 p.m. and 5/15/24 at 3:20 p.m. was conducted inside of room [ROOM NUMBER]. The observation revealed 311- B had a wall that was damaged. The corner of the wall beside the bed had patches of silver and white paint coming out from underneath the peach-colored wall. The corner of the wall had deep scratches and missing paint. Behind the head of the bed there was white and silver color paint coming out from underneath the peach-colored wall. During an interview on 05/15/24 at 3:20 p.m., Staff A Registered Nurse (RN), Unit Manager (UM) stated resident rooms were inspected daily by both the Certified Nursing Assistant (CNA) and Unit Manager. Staff A RN, UM stated when there was a concern in a room staff documented the concern in an electronic maintenance system and stated she personally reported the problem to the housekeeping department or maintenance department pending the concern. Staff A RN, UM stated she had never noticed the damaged walls before in room [ROOM NUMBER]. During an interview on 05/16/24 at 9:54 a.m., the Administrator stated all rooms are inspected by the department heads which was called the concierge service. The Administrator stated the department heads were assigned specific rooms throughout the facility and those rooms were observed for any damage or environmental concerns that needed to be fixed. The Administrator stated any concerns would be documented on the electronic maintenance system. He stated the entries develop into work orders to be fixed. Review of the Concierge Program Rounds-Resident Interview/Room Observations form, undated, showed guidance for employees with a list of questions to interview residents, and a list of items in the areas of Environmental Issues, Safety Issues and Clinical Issues to be observed. There was a section of the form with blank lines for additional information on the bottom of the form. During an interview on 05/16/24 at 10:07 a.m., the Administrator stated Department Heads completed the Concierge Program Rounds-Resident Interview/Room Observations form and report the findings in the morning meeting daily. The Administrator stated even though walls and floors were not on the list of issues to circle, the section on the form with blank lines was to be used for areas of concerns. The Administrator stated he would expect his department heads to complete the blank section of the form with any additional issues that would include any damaged walls or floors. The Administrator stated all environmental and safety issues would need to be documented in the electronic maintenance system to be fixed. Review of the facility's policy Physical Environment, effective date 01/01/2020, revealed the following: Policy: A safe, clean, comfortable and home-life environment is provided for each resident/patient, allowing the use of personal belongings to the greatest extent possible. Sufficient space and equipment in dining, health services, recreation and program areas are provided to enable staff to provide resident/patients with needed services. All essential mechanical, electrical and resident/patient care equipment is maintained in a safe operating condition through the facility's Preventative Maintenance Program. 40775 41015

Based on interviews and record review, the facility failed to ensure accuracy of resident comprehensive assessment for three residents (#64, #81, and #158) out of fifty-two sampled residents. Findings included: A review of Resident #64's medical record revealed Resident #64 was admitted to the facility on [DATE] with diagnoses of dementia, psychosis, anxiety disorder, and need for assistance with personal care. An observation was conducted on 5/13/2024 at 10:49 AM of Resident #64 in the resident's room. Resident #64 was observed resting in bed with bilateral, one quarter length bed rails up. Resident #64's representative was observed in the room and was interviewed. Resident #64's representative stated Resident #64 has bed rails to her bed because They keep her in the bed. A review of Resident #64's quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 4/15/2024, revealed under Section P-Restraints and Alarms, Bed Rails: Not used. An observation was conducted on 5/14/2024 at 10:10 AM of Resident #64 in the resident's room. Resident #64 was observed resting in bed with bilateral, one quarter length bed rails up. A review of Resident #81's medical record revealed Resident #81 was admitted to the facility on [DATE] with diagnoses of psychosis, dementia, anxiety disorder, and Hemiplegia and Hemiparesis following cerebrovascular disease affecting the right side. An observation was conducted on 5/13/2024 at 11:19 AM of Resident #81 in the resident's room. Resident #81 was observed sleeping in bed with bilateral, one quarter length bed rails up. A review of Resident #81's annual MDS assessment, with an ARD of 3/24/2024, revealed under Section P-Restraints and Alarms, Bed Rails: Not used. An observation was conducted on 5/14/2024 at 1:35 PM of Resident #81 in the resident's room. Resident #81 was observed sleeping in bed with bilateral, one quarter length bed rails up. A review of the medical record for Resident #158 revealed she was admitted to the facility on [DATE] from an acute care hospital. A review of physician orders, dated 3/8/2024, revealed Resident #158 may be discharged to home. A review of progress notes, dated 3/8/2024, revealed [Resident #158] is stable and was discharged home today with resident's medications given to the family with documentation of discharge instructions. A review of medical record Minimum Data Set (MDS), dated [DATE], for Resident #158 revealed in Section A-Identification Information, discharge date [DATE] and Discharge Status Short Term General Hospital. An interview was conducted on 5/15/2024 at 11:30 AM with Staff G, Licensed Practical Nurse (LPN), Clinical Reimbursement Specialist (CRS). Staff G, LPN/CRS verified the MDS Section A, dated 3/8/2024, revealed Resident #158 was discharged to a short-term general hospital, return not anticipated. Staff G LPN/CRS verified the progress note dated 3/8/2024 indicated Resident #158 was discharged home. Review of the Policy and Procedure titled Discharge Management, dated October 2021, revealed the following: Policy: The facility's preadmission process is designed to provide residents with access to the appropriate care, health plan professional(s), and service(s) based on their level of care, evaluated needs, and the facility's ability to meet those needs. Residents are referred, transferred, or discharged based on their evaluated needs and by order of their attending physician. Discharges will be based on the resident's clinical condition and will occur as soon as reasonably possibly following the physician's discharge order. Procedure: 1. Formulate the initial discharge plan and projected date (based on diagnosis, level of functioning, rehab prognosis, clinical goals) through the Interdisciplinary Team (IDT) at the initial IDT Plan of Care meeting. 2. The Director of Nursing (DON) is accountable for discharge management coordination. Review of the Policy and Procedure titled Resident Assessment Instrument: MDS Section Completion by Discipline, dated October 2023, revealed the following: Overview: The IDT members participate in the Resident Assessment Instrument (RAI) to assess each Resident's individual needs and strengths through an approach that assesses problems or conditions and collaboration on appropriate interventions to achieve a Residents' highest level of functioning possible and maintain their sense of individuality. Guidelines: The RAI will be coordinated by a Registered Nurse (RN) who signs and certifies the completion of the assessments. Section A Identification Information is completed by Nursing. 48823

Based on interviews and record reviews, the facility failed to ensure informed consent for the use of bedrails was obtained prior to installation of bedrails and failed to ensure residents were assessed properly for the use of bedrails prior to installation for three residents (64, #81, and #311) of three residents sampled for bedrail use. Findings included: 1. A review of Resident #64's medical record revealed Resident #64 was admitted to the facility on [DATE] with diagnoses of dementia, psychosis, anxiety disorder, and need for assistance with personal care. An observation was conducted on 5/13/2024 at 10:49 AM of Resident #64 in the resident's room. Resident #64 was observed resting in bed with bilateral, one quarter length bed rails up. Resident #64's representative was observed in the room and was interviewed. Resident #64's representative stated Resident #64 has had bed rails to her bed because, They keep her in the bed. Resident #64's representative stated Resident #64 was not informed of the risk of bed rail use and did not sign a consent for the bed rail use. A review of Resident #64's Physical Therapy Discharge Summary, dated 4/3/2024, revealed under the section titled Analysis of Functional Outcome/Clinical Impressions at the time of discharge, Resident #64 continued to require maximum assistance with all functional bed mobility/repositioning tasks and was discharged from therapy having likely achieved her maximum functional potential. The Physical Therapy Discharge Summary did not address the use of bedrails. A review of Resident #64's care plan revealed a focus area, last revised 8/11/2021, Resident #64 had an activities of daily living (ADL) self-care performance deficit related to impaired cognition and limited range of motion to the lower extremities with contracture. Interventions included to provide assistance of two staff for bed mobility when turning and/or repositioning. Resident #64's care plan did not reveal interventions related to the use of bedrails. A review of Resident #64's quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 4/15/2024, revealed under Section P-Restraints and Alarms, Bed Rails: Not used. A review of Resident #64's medical record did not reveal documentation related to alternative methods used prior to installation of the bed rails or informed consent related to the use of bed rails. An observation was conducted on 5/14/2024 at 10:10 AM of Resident #64 in the resident's room. Resident #64 was observed resting in bed with bilateral, one quarter length bed rails up. 2. A review of Resident #81's medical record revealed Resident #81 was admitted to the facility on [DATE] with diagnoses of psychosis, dementia, anxiety disorder, and hemiplegia and hemiparesis following cerebrovascular disease affecting the right side. An observation was conducted on 5/13/2024 at 11:19 AM of Resident #81 in the resident's room. Resident #81 was observed sleeping in bed with bilateral, one quarter length bed rails up. A review of Resident #81's Occupational Therapy Plan of Care, dated 2/23/2024, revealed under the section titled Initial Assessment, Resident #81 required maximum assistance (76% to 99%) with rolling bed mobility with a long term goal to roll to the left side with minimal (1% to 25%) assistance in order to improve the resident's ability to assist caregivers during brief changes. The Occupational Therapy Plan of Care did not address the use of bedrails. A review of Resident #81's care plan revealed a focus area, last revised 2/22/2024, Resident #81 had an ADL self-care performance deficit related to impaired cognition, weakness, impaired balance, and decline in function. Interventions included to provide assistance of two staff for bed mobility when turning and/or repositioning. Resident #81's care plan did not reveal interventions related to the use of bedrails. A review of Resident #81's annual MDS assessment, with an ARD of 3/24/2024, revealed under Section P-Restraints and Alarms, Bed Rails: Not used. A review of Resident #81's medical record did not reveal documentation related to alternative methods used prior to installation of the bed rails or informed consent related to the use of bed rails. An observation was conducted on 5/14/2024 at 1:35 AM of Resident #81 in the resident's room. Resident #81 was observed sleeping in bed with bilateral, one quarter length bed rails up. 3. A review of Resident #311's medical record revealed Resident #311 was admitted to the facility on [DATE] with diagnoses of need for assistance with personal care, dementia, maxillary fracture, fracture of right orbital floor, and pathological hip fracture. An observation was conducted on 5/13/2024 at 2:04 PM in Resident #311's room. Resident #311 was observed sleeping in bed, positioned on her back, with bilateral, one quarter length bed rails up. A review of Resident #311's Occupational Therapy plan of care, with a start of care date of 5/13/2024, revealed Resident #311 had a functional deficit in rolling bed mobility, and was dependent on facility staff for rolling side to side in bed. The Physical Therapy plan of care did not address the use of bedrails. A review of Resident #311's care plan revealed a focus area, initiated on 5/13/2024, Resident #311 was at risk of developing wounds and had actual wounds. Interventions included to encourage/remind/assist to turn/reposition as needed or requested, observe for any new areas of skin breakdown, treatment as ordered, and observe that dressing is covering and adhering. Report loose dressings to the nurse. Resident #311's care plan revealed a focus area, initiated on 5/13/2024, Resident #81 had an ADL self-care performance deficit. Interventions included to provide assistance of one staff for bed mobility when turning and/or repositioning. Resident #311's care plan did not reveal interventions related to the use of bedrails. A review of Resident #311's medical record did not reveal documentation related to alternative methods used prior to installation of the bed rails or informed consent related to the use of bed rails. An observation was conducted on 5/14/2024 at 10:09 AM in Resident #311's room. Resident #311 was observed sleeping in bed, positioned on her back, with bilateral, one quarter length bed rails up. An interview was conducted on 5/14/2024 at 1:14 PM with Staff H, Registered Nurse (RN) and Unit Manager (UM). Staff H, RN UM stated new residents were assessed for the use of bedrails by the admitting nurse and therapy staff. When the assessment is completed, nursing staff will notify the maintenance staff to install the appropriate bedrails. Staff H, RN UM was not able to state if Resident #81 was able to use bedrails and stated Resident #64 did use bedrails. A follow up interview was conducted on 5/16/2024 at 11:06 AM with Staff H, RN UM. Staff H, RN UM stated the bedrails to Resident #311's bed were already installed when the resident was admitted to the facility, and she was not sure if the resident was able to use them for turning and repositioning. An interview was conducted on 5/16/2024 at 12:43 PM with the facility's Director of Nursing (DON). The DON stated therapy staff evaluate residents for the safe use of bedrails upon admission to the facility. Once the therapy referral is received, therapy staff will evaluate the resident to ensure the bedrail use is appropriate. The DON also stated a bedrail assessment is completed upon admission by the admitted nurse, but the DON was not able to state how the nursing staff perform the assessment. The DON stated she would expect bedrails to be installed only after the resident was assessed to ensure the use is appropriate because bedrails may not be safe for the resident to have. The DON was not able to state if a consent for bedrails was required or how often an assessment for bedrail use should be performed, but the DON stated the use of bedrails should be reflected in the resident's care plan. A review of the facility policy titled Side Rails-Assistive Device, effective in October 2021, revealed under the section titled Overview side rail(s) will not be used unless or until all other alternatives have been exhausted. If a side rail is used the facility must ensure correct installation, use, and maintenance of rail. The policy also revealed under the section titled Guidelines on admission, readmission, quarterly, and with significant change in condition, the resident will be assessed for ability to turn, reposition, enter and exit the side to determine if an assistive device or a side rail is required for mobility. The Assistive Device/Side Rail Algorithm may be used to determine necessity of the assistive device/side rail and alternatives. The interdisciplinary team (IDT) will review with the resident and/or representative the assessment findings as part of the resident care plan process. The facility will include a risk/benefit discussion and obtain informed consent. Resident and resident representative, if indicated, will be educated on the use of the assistive device. Update the Care Plan and Kardex to include use of assistive device. Re-evaluate resident status at least quarterly or with significant changes at the plan of care and/or standards of care meeting to determine if assistive device is still required.

Based on observations, interviews, and record review, the facility failed to provide an accommodation of resident needs related to mobility devices for one resident (#39) out of fifty-two sampled residents. Findings included: A review of the medical record revealed Resident #39 was admitted to the facility on [DATE] with diagnoses including Multiple Sclerosis (MS), obesity, and Lupus Erythematosus. An interview was conducted on 5/14/2024 at 9:55 AM with Resident #39 in the resident's room. Resident #39 was observed resting in bed during the interview. Resident #39 stated she wanted to plan some outings for the upcoming summer season, but the facility had taken her wheelchair and left her without one. A tour of Residents #39's room and bathroom was conducted, and a wheelchair was not observed in the resident's room. Resident #39 stated she required use of a high back wheelchair due to having Lupus. A review of Resident #39's care plan revealed the following: Focus, last revised 2/3/2023, Resident #39 had an activity of daily living (ADL) self-care performance deficit as evidence by Lupus, MS, morbid obesity, impaired mobility, and lack of participation/motivation. Interventions/Tasks included locomotion with use of a wheelchair and total mechanical lift with use of 2 staff to the chair for transferring. A review of Resident #39's quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 4/9/2024, revealed under Section C-Cognitive Patterns, a Brief Interview for Mental Status (BIMS) score of 15, indicating Resident #39 was cognitively intact. The MDS assessment also revealed, under Section GG-Functional Abilities and Goals, Resident #39 used a wheelchair for mobility within the last 7 days. An interview was conducted on 5/16/2024 at 11:09 AM with Staff I, Occupational Therapist (OT). Staff I, OT stated residents are assessed by therapy for the type of chair they may need, but they do not always assign a chair for the resident. Staff I, OT also stated Resident #39 did not normally use a wheelchair at all and the resident, Just wants it to sit in her room. Staff I, OT was not able to state why Resident #39 was not assigned a wheelchair or why the resident did not have a wheelchair available to use in her room. An interview was conducted on 5/16/2024 at 12:56 PM with the facility's Director of Nursing (DON). The DON stated therapy staff assessed residents upon admission for the use of assistive devices. After the completion of the assessment, the facility provides the needed assistive device to the resident. The DON stated even if a resident does not use the device often, it is left with the resident for the entirety of their stay at the facility for their use. The DON also stated Resident #39 often refuses to get out of bed and is encouraged to get out of bed by staff, but the DON was not able to state why the resident did not have a wheelchair available for her use.

Based on observations, interviews, and record review, the facility failed to resolve a resident grievance, to their satisfaction, in a timely manner for one resident (#143) out of the fifty-one sampled residents. Findings included: A review of the Admission Record for Resident #143 showed he was initially admitted to the facility on [DATE] with a primary diagnosis of muscle wasting and atrophy. A review of the Minimum Data Set (MDS), dated [DATE], in Section C-Cognitive Patterns Resident #143 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating intact cognition. On 05/13/24 at 9:30 a.m., Resident #143 reported he had concerns regarding missing clothes. The resident stated he had to wear other residents' clothes because the facility had been unable to locate his clothes. He stated he reported this concern to staff from the laundry and to the social services department, and they still could not find his clothing. The resident stated the clothing went down to the laundry in a bag with his name on it and the clothing was still lost. On 05/15/24 at 1:25 p.m., Resident #143 reported he had one sweater while tugging at the sweater he had on. He stated his clothes had been gone for weeks. The resident stated someone from social services came and spoke with him on Monday and took a list of the items he had missing and photocopied it. The resident had listed the following items as missing: 03/30 2 pairs blue denim jeans (34x29 long) 1 pair black cotton acrylic slacks 1 black cotton acrylic sweater 1 black cotton acrylic hoodie 2 pairs medium T-shirts black 2 pairs cotton T-shirts grey 4 pairs black socks 4 pairs white ankle socks 4 pairs cotton acrylic boxer underwear 1 lime green long sleeve acrylic sweater 04/30 (wash bag) 4 pairs black ankle socks 1 pair grey socks 1 cap 1 pair brown gloves 3 pairs black boxer shorts 1 pair of shorts 1 pair of black shorts 1 dark green sweater 1 blue medium sweater 1 black v neck T-shirt 1 red medium T-shirt 1 large violet T-shirt 1 grey T-shirt 1 dark blue T-shirt 1 dark grey T-shirt (Photographic evidence obtained). Resident #143 stated the Unit Manager told him she was going to take care of the concern 4 to 5 weeks ago. He stated the facility kept telling him the same thing, that they reported it to the laundry manager and that person tried to push some other stuff on him that did not belong to him. He stated he was missing underwear, socks, and matching sweaters and pants. He stated originally the staff said they would reimburse him. He stated he was frustrated because this had been ongoing for so long. Resident #143 reported he was reluctant to send the second bag down because he didn't want his items lost. He stated his name was on the second bag, and the Certified Nursing Assistant (CNA) made sure his name was on it. A review of the Grievance/Concern Log from January 2024 to present showed Resident #143 had only filed one grievance on 04/29/24 for missing items. The date resolved was listed as 05/06/24. A review of the Grievance/Concern Report, dated 04/29/24, revealed the following: Description: missing laundry. Resident stated he sent down a mesh bag with his items. The grievance was assigned on 04/29/24 and resolved by 05/08/24. The action taken to resolve the grievance was laundry and lost and found searched and the items were not found that matched the list given. Items were not listed on the inventory sheet. The resident was offered items from donated clothing on 05/06 and he declined. It was offered again on 05/13. The summary of findings showed the resident stated the items were not labeled and were mostly dark so he couldn't write in them. He was educated on the iron on capability the facility had. Will continue to periodically search for items listed and follow up with the resident. On 05/15/24 at 1:35 p.m., Staff E, Registered Nurse (RN)/Unit Manager (UM), confirmed Resident #143 reported to her he was missing clothing. He had a list of items he was missing. A grievance was filed, and they were going to reimburse him. This was reported to her a couple of weeks ago. She went to file a grievance but someone else had already filed the grievance. On 05/15/24 at 2:18 p.m., the Social Services Director (SSD) reported that the items the resident alleged were missing were not listed on his inventory sheet. She stated the facility staff, and the resident were responsible for documenting things on the inventory sheet during admission. They offered him items from the lost and found but he did not want those items. They asked him if he wanted them to reorder things and he didn't want them to do that. On 05/15/24 at 2:24 p.m., an interview was conducted with Resident #143. The resident stated the facility had not mentioned anything to him about helping him reorder things. On 05/16/24 at 9:32 a.m. the Administrator reported they offered the resident clothes from the lost and found and he didn't want those. He stated he would get it taken care of, but they had to get approval from corporate to cut a check for the items. On 05/16/24 at 11:31 a.m., the Training Coordinator Area Manager stated Resident #143 told her the clothes were in a bag and the bag was given to a CNA. She interviewed all the laundry staff and none of the staff confirmed they received a bag from a CNA. They were unable to identify who the CNA was. The policy and procedure provided by the facility Grievance/Concern Management with an effective date of February 2021 revealed the following: Policy: -Residents/representative has the right to present concerns on behalf of themselves, and/or others to the staff and/or administrator of the facility, to governmental officials, or to any other person. The concern may be filed verbally or in writing, and the reporter may request to remain anonymous. -Residents/representative have the right to recommend changes in policies and services of facility personnel; and to join with other residents or individuals within or outside the facility to work for improvements in resident care, free from restraint, interference, coercion, discrimination, or reprisal. -These rights include access to ombudsman and advocates and the right to be a member of, to be active in, and to associate with, advocacy or special interest groups. -These rights also include the right to prompt efforts by the facility to resolve resident concerns, including concerns/grievances with respect to the behavior of other residents. Procedure: I. At, during, or after admission, staff will provide: o An explanation of the facility concern process o A copy of the concern/grievance form o An explanation of where concern forms are located, and that staff will provide a form should it be requested o Guidance on assistance available to residents/family members who are unable to complete the form unassisted o The names, job titles, and telephone numbers of employees responsible for implementing the facility's concern procedure. This information is found in the Admission Booklet and includes the address and toll-free telephone numbers and email addresses for the Ombudsman and the Agency and other survey agencies. o Outside resources available to the resident: - Ombudsman -Department of Health -Facility specific options such as a toll-free number for reporting concerns 2. The facility will prominently display a poster that includes the following: o The contact information of the Grievance Official to include his/her name, business address (mailing and email address), and business phone number; o A reasonable expected time for completing a review of the concern; o The right to obtain a written decision regarding the concern; o Reference to independent entities with whom concerns may be filed 3. Residents/resident representative who are unable to complete a written concern will be assisted by staff to prepare and submit the form. 4. The NHA is responsible for oversight of the concern process. 5. The Social Services Representatives/Grievance Official in collaboration with the NHA will be responsible for assigning the concern to the appropriate department for investigation. Social Services will monitor and document resident/family satisfaction upon completion of the investigation and the summary of findings/conclusion. 6. Social Services Director in collaboration with the NHA will be the Grievance Official at the facility 7. The facility leadership team will review and discuss concerns and the progress of an investigation(s) and resolution(s). 8. The department involved will document the concern and record the resident/resident representative's satisfaction with the resolution to the concern. 9. The Resident Council will be reminded of the name and location of the grievance officer; how to file a concern; that they may file verbally or in writing and may file anonymously. This reminder will include where they can find the poster with the number where they can make an anonymous concern. 10. The concern process will be reviewed at a minimum annually with resident council. 11. Concern forms are confidential, protected QI documents and are not copied. 12. Concerns are tracked, trended and reported in the monthly QAPI Committee Meeting. 13. Retain grievance concern report and logs for 3 years. Others will be shredded. 14. Complete a concern report investigation with summary and conclusion. 15. Social Services staff will provide information regarding compliance line information for unresolved concerns .

Based on observations and interview, the facility failed to ensure sufficient staff with the appropriate competencies and skills-sets to perform the functions of the food and nutrition service, taking into consideration resident assessments and individual plans of care related to dietary staff not properly implementing adequate kitchen hygiene, proper sanitation practices, proper food labeling and storage, and appropriate serving of meals affecting 158 out of 168 residents in the facility. The likelihood of serious injury and/or death to 158 residents as a result of the facility's failure to prepare, store and serve food in accordance with professional standards for food service safety resulted in the determination of Immediate Jeopardy on [DATE]. The findings of Immediate Jeopardy were determined to be removed on [DATE] and the severity and scope was reduced to a D. Findings included: On [DATE] starting at 9:30 a.m. a tour of the facility's kitchen was conducted which revealed: An observation was made of kitchen floors and walls which appeared dirty and covered with miscellaneous food particles. (Photographic evidence obtained) The left side of the main reach-in refrigerator was observed with condensation and black bio-growth on the outside surface. The inside was noted with water on the floor of the refrigerator and food sitting in the pool of water. An immediate interview was conducted with Staff A, Cook on [DATE] at 9:32 a.m. He revealed the refrigerator had been leaking for some time and the facility's administration was aware. He stated it would have been at least 3 months. Observations during the kitchen tour of the inside of the main refrigerator revealed expired and undated foods, and approximately 20 different food items/containers that could not be identified. Further investigation of the inside of the main refrigerator revealed: o One food container labeled rice which when opened revealed a foul/rancid odor. o An undated and unlabeled pasta salad with fuzzy, green bio growth, which was prepared by the facility kitchen staff and contained within a re-useable plastic container that was unlabeled and undated. o A half circle of unidentified meat (appeared to be unsliced cooked deli meat), undated and unlabeled, wrapped in plastic wrap (not original packaging) with use first sticker. o A large ham wrapped in plastic wrap (not original packaging) unlabeled and undated with use first sticker. o A container of black beans dated ,d+[DATE] in a reusable plastic container with lid (not original packaging). o A container of diced tomatoes dated ,d+[DATE] in a reusable plastic container with lid (not original packaging). o A container labeled garden noodles with black and white bio growth on the surface of the food, dated [DATE]. o An opened plastic tub of Pork base with no opened or use by date. A delivery sticker was dated [DATE]. An interview was conducted at the time of the observation on [DATE] at 9:57 a.m. with Staff V, Registered Dietitian (RD). She looked at the pork base and said it should be good for a while but she did not know for how long or when it was opened. o All other observed food items/containers were unlabeled, undated, and the food items were unidentifiable. A second reach-in refrigerator was observed and revealed: o An unlabeled/undated container of unidentifiable food, with a use first label. An interview was conducted immediately with Staff F, Dietary Aide. Staff F, Dietary Aide said she believed it was peanut butter and jelly someone had mixed. (Photographic evidence obtained) o A bag of shredded carrots with a printed manufacturer date best if used by [DATE] (16 days past the manufacturer date). (Photographic evidence obtained) o A box of grape tomatoes with white bio-growth. (Photographic evidence obtained) A walk-in refrigerator was observed and revealed: o 2 bags of onions and peppers with a stamped date of [DATE] The 2 bags of onions and peppers were noted to be soft and partially liquefied. The liquid was leaking out of the bag and through the box onto the bread packaging which was stored underneath. During an interview on [DATE] at 10:10 AM with the Registered Dietitian (RD), she inspected the 2 bags of onion and peppers and reported she was unsure of the expiration date of the item and unsure how long the 2 bags of onion and peppers were in the walk-in refrigerator. (Photographic evidence provided) o A container of vanilla ice cream was observed on the shelf in the walk-in refrigerator. The container was soft to the touch. (Photographic evidence obtained.) o A bowl, plastic lid, butter, and an orange slice were observed on the floor under the walk-in refrigerator. (Photographic evidence obtained.) An observation of the Walk-in freezer revealed: o built-up ice and icicles on and around the 2 freezer vents mounted on the top rear of the freezer. o solid frozen icicles were noted to be enclosing a box of shredded pork, and a bag of mixed vegetables. During an interview on [DATE] at 10:12 AM, the RD reported she was not aware of the build-up of ice in the freezer, and it should have been reported to maintenance. (Photographic evidence provided) o trash and food on the floor under the shelves. (Photographic evidence obtained) o two open clear plastic bags of frozen meat patties in the freezer, not labeled or dated, and not in original box. (Photographic evidence obtained) An observation was made of a bucket with water dripping from the steamer. During an immediate interview, Staff A, Cook stated he did not know how long the water had been collecting in the bucket. (Photographic evidence obtained) The wall behind the juice machine was noted with dirt and debris on the surface. A large plastic container located next to the prep table was noted to be covered with a clear lid. Closer inspection revealed that the container contained a white powder that appeared to be flour which was noted to have brown/gray solid substances in the flour. During an interview with Staff V, Registered Dietician (RD) on [DATE] at 10:05 AM, she removed some of the solid substance from the plastic container and reported she did not know what the substance was, stating someone must have spilt something. Staff V, RD reported the flour should have been discarded. (Photographic evidence obtained). A clean pot rack was noted close to the 3-compartment sink. The rack was noted to have several pots and pans stored in the upward position instead of the food surface being facedown (Photographic evidence provided). Breakfast food items were observed on the countertop by the stove. The items included pancakes, French toast, and sausage wrapped in clear film wrap. An immediate interview with Staff A, Cook was conducted. He stated they were leftovers from breakfast, and he would be putting them away. At approximately 11:20 a.m. Staff A, Cook was observed taking the items to the walk-in cooler for storage. In an interview, Staff A, Cook confirmed the items had been sitting on the countertop by the stove for at least three hours, stating they would probably be out of the required temperature range. A tour of the dish machine area revealed floor surfaces with dirt, grime and food remains. During the tour, two dietary aides, Staff B and Staff C, were observed operating the dish washing machine. They were asked to test the machine's water temperature and chlorine sanitization levels. Staff B, Dietary Aide was observed conducting a water temperature and chemical sanitation test. The chemical test trip was observed as white, indicating the sanitization chemicals were not at appropriate levels. In an immediate interview, Staff B, Dietary Aide stated the test strip should be a light purple to a dark purple color, meaning 50 to 100 parts per million (PPM). Both aides confirmed the dish machine was not working. They stated the problem had been on- going and the machine worked on and off. The aide stated they believed Staff V, RD, and the assistant nursing home administrator (ANHA) were aware. An immediate follow -up was conducted with Staff W, Certified Dietary Manager (CDM.) She stated she did not know the machine was not working. She said, it appears we have a sanitization issue. The machine is not reaching the required PPM. She stated the PPM levels should be between 50 and 100 for the dishes to be considered sanitary. Further observation of the facility's dish machine revealed there was a white chalky substance noted on the top of the dish machine. Additionally, both the dirty and clean doors of the dish machine were noted to be coated with the white chalky substance. (Photographic evidence obtained) An observation was made of cleaning equipment and a dustpan full of dirt/dust in the corner of the kitchen on the floor. A plastic bag of potatoes was observed under a prep table in the kitchen. The bag contained potatoes that were rotting and producing liquid (Photographic evidence obtained). An immediate interview was conducted with Staff A, Cook on [DATE] at 10:15 a.m. He said, those are baked potatoes. We just had those. He said he did not know why they were on the shelf. The bag was picked up and had liquid in the bottom. Staff V, RD picked up the bag and said uuuggghhh. The bag had no label or date. Additionally, a paper bag of uncooked potatoes was on the shelf. The bag was observed to have liquid leaking from it. The potatoes in the bag appeared rotten and wet. (Photographic evidence obtained) A mop bucket full of dark gray, dirty water with the mop sitting in it was observed. Staff F, Dietary Aide said she believed the water had been sitting there since the weekend, ,d+[DATE] days prior. Observations of the vent hood revealed storage of two cans of red beans and rice, a can of chicken noodle soup, a can of mackerel, coffee creamer, a portable speaker, and a hair clip. (Photographic evidence obtained) The lights and light cages located under the range hood was noted to be covered in dust. Additional observation revealed the convection oven was located under the range hood and was noted to have debris on top of the unit. During an interview on [DATE] at 10:16 AM with Staff A, cook, he reported the top of the convection oven was used to heat/raise bread and that he does not remember when it was last cleaned. Staff A reported a company comes in to clean the range hood but does not know when the vendor last came. Inspection of an orange sticker mounted on the left corner of the range hood revealed that the vendor last inspected the range hood on [DATE]. (Photographic evidence provided). Observation of the bottom of the prep table revealed an unlabeled, undated container of brown liquid. An interview was conducted immediately with Staff A, Cook. He said he did not know what was in the container or how long it had been there. (Photographic evidence obtained) A dry storage container containing salt was observed under the kitchen prep table, and a scoop was stored in the salt. The scoop was observed to remain in the salt on [DATE]. A follow-up interview was conducted on [DATE] at 11:33 a.m. with Staff V, RD. She confirmed the scoop should not have been stored down in the salt. (Photographic evidence obtained) Observation of the milk chest cooler revealed a buildup of ice and sour milk spilled in the bottom. The edges under the lid were also dirty and stained with miscellaneous food/debris. (Photographic evidence obtained) Observation of a vent in the dry storage room revealed dust, dirt, and bio growth on the surface. Review of the dish machine logs revealed the dish machine temperature and sanitation was last tested on [DATE]. The log showed the same numbers entered for wash temp, rinse temp, final rinse, and sanitizer PPM. The employee initials showed one person initialed the log every day for all 3 meals. An interview with the RD revealed the initials belonged to the ANHA. The log revealed she indicated she worked every day and checked the machine temperature for breakfast, lunch, and dinner. The log was noted blank (no entries) from [DATE] to [DATE]. Review of a coffee machine temperature log dated [DATE], showed the same employee (nursing home administrator) had signed the temperature logs every day from [DATE]th to [DATE]. The log was blank (no entries) from [DATE]th through [DATE]. Review of cleaning checklists revealed missing documentation and blank logs. An interview was conducted on [DATE] at 9:40 a.m. with Staff V, RD. She stated she worked at the facility full time. She stated she was not aware there were outdated and expired food in the kitchen. She stated she expected staff to discard old foods every three days, stating that is very basic. All kitchen employees should know that. She stated they had cleaning checklists, but it was hard to follow - up because they did not have enough staff. She stated the kitchen manager left about a month prior and the administration had contracted with a traveling CDM (certified dietary manager) to assist in managing the kitchen. An interview was conducted on [DATE] at 9:55 a.m. with Staff W, CDM. She stated she had started a week earlier. She stated she spent two days the week prior organizing the dry food storage. She stated she removed moldy bread and re-ordered fresh bread. She stated she noted the facility did not have hand washing bowls and chemicals, and she had notified the NHA (nursing home administrator). She stated she did not know the refrigerator was full of outdated food. She said, I would have taken care of it. I would expect the staff to throw out old food and clean the kitchen as scheduled. Staff W, CDM stated she was not aware the dish machine was not working, and that the freezer had a problem. Staff W, CDM said, our biggest problem was staffing. three staff members called out. There has been a call out every day which means many tasks are not attended. A second kitchen tour was conducted during lunch service on [DATE], which revealed: At 11:20 a.m. upon entering the kitchen a cart was noted to be out of the refrigerator near the serving area loaded with fruit plates and containing cottage cheese. At 11:50 a.m. Staff V, RD was observed taking holding food temperatures. The RD temped the first fruit plate and cottage cheese at 57.3 F. The RD removed a second fruit plate with cottage cheese and checked the temperature in multiple locations on the plate. This plate temped at 60 F. In an immediate interview Staff V, RD said the fruit plates with cottage cheese should be held at 41 F or lower. Staff V, RD was observed disposing of the two plates of fruit and cottage cheese she tested ; however, the remaining plates of fruit and cottage cheese from the same cart were observed being placed on trays and served at lunch. On [DATE] at 11:30 a.m. Staff A, Cook was observed rolling a cart which contained uncovered bread around the kitchen. He left the stove area and rolled the cart towards the dirty dishes area, then proceeded to the clean dish area. He then rolled the cart to the walk -in cooler and grabbed some milk and then rolled the cart back to the prep area. The bread was uncovered and exposed to the elements during this process. On [DATE] at 11:42 a.m. Staff A, Cook was observed going to the dirty pot sink and pulling out a dirty stainless-steel pot, lid, and food processor blade out of the sink. He turned the water on and ran it over the pot and blade. He picked up a silver scouring pad and squirted some sanitizer on it and appeared to clean the inside of the pot while running some water over the lid. He took the items to the prep table and placed the blade in the bowl and put it on the food processor base. The lid was visibly soiled with a brown/purple puree. Staff A, Cook then placed the dirty lid on the food processor and began to puree bread. An immediate interview was conducted with Staff A, Cook. While reviewing photographic evidence, he said, I didn't notice. Staff A, Cook was visibly frustrated; took the lid off and went to the sink to wash the lid. Staff A, Cook did not discard the contaminated food. He then placed the lid back on the bowl and continued making the pureed bread. Staff W, CDM was notified of the situation. She said the food should have been thrown out and started over. (Photographic evidence obtained.) On [DATE] at 12:01 p.m. Staff A, Cook was observed to be serving food on the tray line with no cover on his beard. Non disposable cups, bowls, fruit plates, and plate covers were being utilized for the lunch service. On [DATE] at 12:10 p.m. an interview was conducted with Staff B, Dietary Aide. Staff B, Dietary Aide said the lids and cups being used were washed in the dish machine that was not sanitizing. She said, yes, and they are dirty. They ain't clean. Staff B, Dietary Aide said they did not test the dishwasher chemicals this morning. She said, the same number just gets written every day. Continued observation starting at 12:15 p.m. revealed the first three trays that came off the line were checked for accuracy based on the meal tickets. The trays had been completed and placed on the cart for delivery prior to being checked. o Tray #1. The ticket listed BBQ riblet sandwich, oatmeal raisin cookies, chocolate pudding ,d+[DATE] cup with 2 tablespoons of whipped topping, pb&j (peanut butter and jelly) sandwich, apple juice, salt, and pepper. The tray did not contain pudding or a pb&j sandwich. (Photographic evidence obtained) o Tray #2. The ticket listed pureed riblet sandwich, pureed creamed corn, pureed fortified mashed potatoes, ,d+[DATE] cup pudding, ,d+[DATE] cup diet pudding, whole milk. The tray did not contain pudding, diet pudding or whole milk. This tray was labeled as an early tray with large portions and fortified. The tray contained regular portions. (Photographic evidence obtained) o Tray #3. The ticket listed Large Portions, BBQ riblet sandwich (1 ,d+[DATE] sand), corn cobette, macaroni salad, 2 cookies, tossed salad, dressing. The tray only had 1 sandwich, 1 corn cobette, pasta salad, and no tossed salad. Regular portions were served. (Photographic evidence obtained) An interview was conducted on [DATE] at 12:23 p.m. with Staff V, RD regarding the completed trays. Staff V, RD said Tray #1 should have had a peanut butter and jelly sandwich on it. She said the dietary aides did not have any made. Staff V, RD looked at Tray #2 and said they did not have any regular pudding, diet pudding or whole milk to give the resident. She confirmed the tray only had regular portions and should have been large portions. When asked what food was fortified, Staff V, RD said she did not know, and she would have to ask the cook. Staff A, Cook said the potatoes were fortified. Staff V, RD reviewed Tray #3 and said it should have been large portions, and she said they did not have tossed salad to put on the tray. She said the issues should have been caught on the line when they were plating the food. An interview was conducted on [DATE] at 9:50 a.m. with the Nursing Home Administrator (NHA) and Assistant Nursing Home Administrator (ANHA.) The NHA observed the expired and outdated cooked foods as Staff A, Cook placed them on a rolling cart. He stated he identified they had a problem because the staff lacked follow-through and that was why he had to let the kitchen manager go. We are aware we have a problem and that is why I have a traveling Certified Dietary Manager (CDM) to help. The NHA was asked why the rotten food had not been thrown out immediately upon noticing an issue. He stated, it's a process and he had to give staff time to fix it. An interview was conducted on [DATE] at 12:27 p.m. with the ANHA. She stated she had completed the dish machine temperature logs herself. When asked if she worked every day during all three meals for the entire month, she stated she only filled out logs. She confirmed she had not taken the temperatures nor tested the dish machine herself. The ANHA stated she had been tasked by the NHA to assist in the kitchen when the kitchen manager left. She stated she was in the kitchen daily and would clean out the refrigerators daily. She stated she did not know how they missed the expired foods, and confirmed the food found was outdated with some items dated [DATE]. The ANHA stated she did not have any training or education on managing a kitchen, or on food safety/sanitation. An observation was conducted in the dining room on [DATE] at 12:38 p.m. One resident had a plate of oranges with no other food. The resident said she had asked for oranges to go with her meal, but they only gave her oranges. The dining room aide present looked at the resident's tray ticket and confirmed she should have had a meal and oranges. On [DATE] at 5:02 p.m., during a meal service kitchen tour, an observation was made of an employee's cell phone next to the clean plates and silverware as Staff D, Cook was about to start meal service. An open cup with drinking water was also noted next to the items. Staff D, Cook confirmed it was her cell phone and her drinking water. On [DATE] at 5:02 p.m., an observation was made of Staff E, Dietary Aide preparing desserts. On the food preparation table, a blue backpack was observed stored next to the clean dishes used for the desserts. Staff E, Dietary Aide confirmed it was her backpack and stated that was where she normally keeps it. An interview was conducted on [DATE] at 5:04 p.m. with Staff V, RD. She stated she never received a copy of the Job Description (JD), which the NHA provided to the surveyor team. She stated her duties were clinical and re-stated she was not responsible for kitchen operations. She stated she was not notified her duties included managing the kitchen or ensuring the kitchen was operational. On [DATE] at 12:20 p.m. an observation was made at lunch service of trays being served to residents in the dining room. Two trays were checked for accuracy based on the tray tickets. o Tray #1 listed grilled cheese, cottage cheese and chocolate milk. The tray only had a grilled cheese sandwich. An interview was conducted immediately with Resident #21. She said I just want the rest of my meal. I didn't get what I ordered. She added I guess they didn't think I was hungry. o Tray #2 listed chicken pot pie, fruit bowl, relish plate (renal), ,d+[DATE] bow tie pasta. The tray contained chicken pot pie, broccoli, a roll, and bowl of fruit. There was no relish plate and no bow tie pasta. A tour of the facility's kitchen on [DATE] starting at 9:25 a.m. revealed: o A plastic bin with lid containing powdered thickener was observed below the prep table and the scoop was sitting on the prep table above the bin uncovered. o A pressure washer was observed being stored in the dry food storage. o Shelves in the clean dish area contained bowls and plates being stored in the upright position. o A personal water bottle was sitting next to a stack of clean glasses on the drink fountain table. o A drink pitcher with two inches of light-yellow unidentifiable liquid was in the reach in cooler with a sticker dated [DATE]. During an interview at 9:46 a.m. the RD said it was an old sticker that is not dissolvable in water and never got taken off. She said there should have been a new dissolvable sticker on the pitcher with the correct date. o Review of Food Temperature Logs showed food temps were not taken for breakfast, lunch, or dinner on [DATE], dinner on [DATE], dinner on [DATE], breakfast or lunch on [DATE]. At 9:55 a.m. Staff A, Cook, confirmed the logbook was the only place food temperatures were documented. He looked at the book and confirmed no one did the food temperatures on the days listed. o At 9:20 a.m. the dishwashing sink was observed clogged and being suctioned by staff with a wet vacuum. Once completed, the wet vacuum was stored under the counter where the clean dishes are set in racks to dry before storing. o An observation at 9:38 a.m. revealed Staff S, Dietary Aide operating the dish machine. Interview with the dietary aide at this time revealed this was the third running of the dish machine since 9:30 a.m. During the observation Staff S, Dietary Aide was asked to test for sanitizer. The staff member was noted to use the test strips and dip it into the water that had remained at the bottom of the machine after the wash was complete. The test trip was noted to come out white in color. Continued interview with Staff S, Dietary aide at this time revealed this color meant the machine fell below the required 50-ppm reading of the test strip, and that it should read between ,d+[DATE]. The staff reported that this was a high temp dish machine. At this time Staff X, CDM interjected and verbalized that the machine is a low temp machine. An Interview was conducted with Staff X, CDM on [DATE] at 9:42 a.m. who revealed staff had run and checked the dish machine at the beginning of their shift and had documented the results on the dishwasher log hanging on the wall. Inspection of the dishwasher log at this time revealed that there was an entry dated ,d+[DATE] for breakfast where the sanitizer ppm was documented as 50 ppm. An interview was conducted on [DATE] at 9:45 a.m. with Staff E, Dietary Aide. She revealed she checked the dish machine around 7:00 a.m. and the sanitizer read 50 ppm. Staff E, Dietary Aide reported that if the ppm was less than 50, she would write it on the dish machine log. She reported there is nothing else to do other than to make sure she writes it down. During kitchen observations of the plating of the midday meal on [DATE] at 11:15 a.m. it was revealed that the staff were plating the meals using regular dishware. An interview with Staff T, RD on [DATE] at 11:20 a.m. revealed that the plates currently being used were the same plates that were washed in the morning. An interview on [DATE] at 11:23 a.m. with Staff S, Dietary Aide and Staff E, Dietary Aide revealed that none of the dishware that was washed in the morning was re-washed. During an observation on [DATE] from 11:29 a.m. to 11: 45 p.m. Staff X, CDM was asked to run the dish machine. The CDM was noted to test the ppm after the second cycle by dipping the test strips directly into the water settled on the bottom of the dish machine. The strip was noted to reveal a purple color which falls within the ,d+[DATE] ppm range. The CDM was asked to run the machine for a third cycle but to place the test strip on the surface of the plate. When tested the strip presented a faint purple color falling below the 50-ppm range. An interview on [DATE] at 11:33 a.m. with Staff X, CDM reported plating of the midday meal was in progress, but that she will now have them go to disposable plates. During observations of the tray line on [DATE] at 11:36 a.m. Staff A, Cook was observed to take food from 3 regular plates that had already been plated and transfer the food to the disposable plates. Staff X, CDM was notified immediately, and she directed the cook to discard the food that had been transferred from the regular plate. Continued observations on [DATE] at 11:47 a.m. revealed the tray line was in progress utilizing disposable plates to plate food. It was noted that regular silverware, cups, and bowls were being utilized. An interview with Staff T, RD at this time revealed that previous trays had been discarded but the current trays were being served. During an Interview on [DATE] at 11:52 a.m. with Staff X, CDM, NHA, Regional [NAME] President, and Regional Nurse Consultant, Staff X, CDM reported when she tested the sanitizer, the readings were inconsistent as the strips on two trials presented too light which means that the ppm was less than 50. She reported the plates were taken off-line, they went to paper, and the vendor had been called for a repair. The NHA reported staff were checking for the sanitizer and they know what to do. He reported the dish machine was checked and working this morning, but it just stopped working when the surveyor was present. Staff X, CDM reported at this time the eating utensils, cups and bowls can be used as they were washed last night. Staff X, CDM reported she can be sure the sanitizer was working last night, as the results were documented on the dish machine log. Review of the Dish machine log at this time revealed there was no entry for [DATE] dinner. Staff X, CDM reported based on the log she could not be sure that the dish machine was working the night prior. She confirmed when the sanitizer is not working, they should utilize paper goods. An interview was conducted on [DATE] 12:05 p.m. with Staff X, CDM. She said food temperatures should be taken every meal by the cook. She agreed they have no way of knowing if food was cooked properly and going out to residents if they are not checking the temperatures. An interview was conducted on [DATE] at 1:35 p.m. with the DON (Director of Nursing). The DON said she spoke with the facility's medical director about residents in the dining room being served today with utensils and bowls that had possibly not been cleaned properly. The medical director said he would like the residents to be monitored for two days for any gastrointestinal upset. The DON said they will be monitoring all residents who ate in the dining room at lunch today. On [DATE] at 11:55 a.m. an observation was made in the kitchen of a clean dish rack with bowls wet nested and the food surface facing upward. The top bowl was noted to have a light-brown liquid in it. An interview was conducted immediately with Staff X, CDM. She confirmed the dish rack was for clean dishes, the bowls should not be stacked when wet and they should be faced down. Upon further inspection she stated someone must have put something dirty on the top shelf that spilled through the rack onto the bowls and container underneath. An interview was conducted on [DATE] at 12:27 p.m. with the ANHA. She stated she had completed the dish machine temperature logs herself. When asked if she worked every day during all three meals for the entire month, she stated she only filled out logs. She confirmed she had not taken the temperatures nor tested the dish machine herself. The ANHA stated she had been tasked by the NHA to assist in the kitchen when the kitchen manager left. She stated she was in the kitchen daily and would clean out the refrigerators daily. She stated she did not know how they missed the expired foods, and confirmed the food found was outdated with some items dated [DATE]. The ANHA stated she did not have any training or education on managing a kitchen, or on food safety/sanitation. An interview was conducted on [DATE] at 1:10 p.m. with the NHA and the Director of Nursing (DON). The NHA said on [DATE] the leadership team had identified issues in the kitchen due to several residents complaining about portion sizes, food temperatures, and not getting requested menu items. The NHA said he first noticed sanitary issues in the kitchen when he and Staff V, RD did an audit of the kitchen on [DATE]. Staff V, RD was no longer employed by the facility and was unavailable for interview. The NHA confirmed during the audit he did look in the refrigerator and corrected issues immediately such as food past their expiration dates, surfaces needing to be wiped down, and pressure washing the floors. He said he did not implement audits because he thought the CDM could fix the problem. The NHA said the CDM was discharged on [DATE] and he put the ANHA in the kitchen to provide oversight until a new CDM started. The NHA said he originally placed the ANHA in the kitchen on [DATE] to help with staffing The NHA said it was never that egregious until ya'll [the survey team] came. Review of a facility policy titled Food and Nutrition Staff Competency, effective [DATE], showed the following: Policy: The competency of associates is evaluated during the hiring process, continues during orientation, includes periodic assessment to determine performance and is sustained through in-service and training. Orientation checklists document attainment of skills listed in the job description. Procedure 2. Upon hire (within 30 days): a. Associates are prepared for their job through [NAME][TRUNCATED]

Based on observations, interviews, record review and policy review, the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety in one of one kitchens observed, and three of three nutrition rooms observed, as evidenced by improper dish washing, unsanitary kitchen area, undated food, expired food, inappropriate food temperatures, unlabeled food, unsanitary preparation of food, food with evidence of bio-growth, and residents not being served according to their prescribed diet orders. This failure created a situation that resulted in the likelihood of serious injury and/or death to 158 residents and resulted in the determination of Immediate Jeopardy on [DATE]. The findings of Immediate Jeopardy were determined to be removed on [DATE] and the severity and scope was reduced to a D. Findings Included: On [DATE] starting at 9:30 a.m. a tour of the facility's kitchen was conducted which revealed: An observation was made of kitchen floors and walls which appeared dirty and covered with miscellaneous food particles. (Photographic evidence obtained) The left side of the main reach-in refrigerator was observed with condensation and black bio-growth on the outside surface. The inside was noted with water on the floor of the refrigerator and food sitting in the pool of water. An immediate interview was conducted with Staff A, Cook on [DATE] at 9:32 a.m. He revealed the refrigerator had been leaking for some time and the facility's administration was aware. He stated it would have been at least 3 months. Observations during the kitchen tour of the inside of the main refrigerator also revealed expired and undated foods, and approximately 20 different food items/containers that could not be identified. Further investigation of the inside of the main refrigerator revealed: o One food container labeled rice which when opened revealed a foul/rancid odor. o An undated and unlabeled pasta salad with fuzzy, green bio growth, which was prepared by the facility kitchen staff and contained within a re-useable plastic container that was unlabeled and undated. o A half circle of unidentified meat (appeared to be unsliced cooked deli meat), undated and unlabeled, wrapped in plastic wrap (not original packaging) with use first sticker. o A large ham wrapped in plastic wrap (not original packaging) unlabeled and undated with use first sticker. o A container of black beans dated ,d+[DATE] in a reusable plastic container with lid (not original packaging). o A container of diced tomatoes dated ,d+[DATE] in a reusable plastic container with lid (not original packaging). o A container labeled garden noodles with black and white bio growth on the surface of the food, dated [DATE]. o An opened plastic tub of Pork base with no opened or use by date. A delivery sticker was dated [DATE]. An interview was conducted at the time of the observation on [DATE] at 9:57 a.m. with Staff V, RD. She looked at the pork base and said it should be good for a while but she did not know for how long or when it was opened. o All other observed food items/containers were unlabeled, undated, and the food items were unidentifiable. A second reach-in refrigerator was observed and revealed: o An unlabeled/undated container of unidentifiable food, with a use first label. An interview was conducted immediately with Staff F, Dietary Aide. Staff F, Dietary Aide said she believed it was peanut butter and jelly someone had mixed. (Photographic evidence obtained) o A bag of shredded carrots with a printed manufacturer date best if used by [DATE] (16 days past the manufacturer date). (Photographic evidence obtained) o A box of grape tomatoes with white bio-growth. (Photographic evidence obtained) A walk-in refrigerator was observed and revealed: o 2 bags of onions and peppers with a stamped date of [DATE] The 2 bags of onions and peppers were noted to be soft and partially liquefied. The liquid was leaking out of the bag and through the box onto the bread that packaging which was stored underneath. During an interview on [DATE] at 10:10 AM with the RD, she inspected the 2 bags of onion and peppers and reported she was unsure of the expiration date of the item and unsure how long the 2 bags of onion and peppers were in the walk-in refrigerator. (Photographic evidence provided) o A container of vanilla ice cream was observed on the shelf in the walk-in refrigerator. The container was soft to the touch. (Photographic evidence obtained.) o A bowl, plastic lid, butter, and an orange slice were observed on the floor under the walk-in refrigerator. (Photographic evidence obtained.) An observation of the Walk-in freezer revealed: o built-up ice and icicles on and around the 2 freezer vents mounted on the top rear of the freezer. o solid frozen icicles were noted to be enclosing a box of shredded pork, and a bag of mixed vegetables. During an interview on [DATE] at 10:12 AM, the RD reported she was not aware of the build-up of ice in the freezer, and it should have been reported to maintenance. (Photographic evidence provided) o trash and food on the floor under the shelves. (Photographic evidence obtained) o two open clear plastic bags of frozen meat patties in the freezer, not labeled or dated, and not in original box. (Photographic evidence obtained) An observation was made of a bucket with water dripping from the steamer. During an immediate interview, Staff A, Cook stated he did not know how long the water had been collecting in the bucket. (Photographic evidence obtained) The wall behind the juice machine was noted with dirt and debris on the surface. A large plastic container located next to the prep table was noted to be covered with a clear lid. Closer inspection revealed that the container contained a white powder that appeared to be flour which was noted to have brown/gray solid substances in the flour. During an interview with Staff V, Registered Dietician (RD) on [DATE] at 10:05 AM, she removed some of the solid substance from the plastic container and reported she did not know what the substance was, stating someone must have spilt something. Staff V, RD reported the flour should have been discarded. (Photographic evidence obtained). A clean pot rack was noted close to the 3-compartment sink. The rack was noted to have several pots and pans stored in the upward position instead of the food surface being facedown (Photographic evidence provided). Breakfast food items were observed on the countertop by the stove. The items included pancakes, French toast, and sausage wrapped in clear film wrap. An immediate interview with Staff A, Cook was conducted. He stated they were leftovers from breakfast, and he would be putting them away. At approximately 11:20 a.m. Staff A, Cook was observed taking the items to the walk-in cooler for storage. In an interview, Staff A, Cook confirmed the items had been sitting on the countertop by the stove for at least three hours, stating they would probably be out of the required temperature range. A tour of the dish machine area revealed floor surfaces with dirt, grime and food remains. During the tour, two dietary aides, Staff B and Staff C, were observed operating the dish washing machine. They were asked to test the machine's water temperature and chlorine sanitization levels. Staff B, Dietary Aide was observed conducting a water temperature and chemical sanitation test. The chemical test trip was observed as white, indicating the sanitization chemicals were not at appropriate levels. In an immediate interview, Staff B, Dietary Aide stated the test strip should be a light purple to a dark purple color, meaning 50 to 100 parts per million (PPM). Both aides confirmed the dish machine was not working. They stated the problem had been on- going and the machine worked on and off. The aide stated they believed Staff V, RD, and the assistant nursing home administrator (ANHA) were aware. An immediate follow -up was conducted with Staff W, Certified Dietary Manager (CDM.) She stated she did not know the machine was not working. She said, it appears we have a sanitization issue. The machine is not reaching the required PPM. She stated the PPM levels should be between 50 and 100 for the dishes to be considered sanitary. Further observation of the facility's dish machine revealed there was a white chalky substance noted on the top of the dish machine. Additionally, both the dirty and clean doors of the dish machine were noted to be coated with the white chalky substance. (Photographic evidence obtained) An observation was made of cleaning equipment and a dustpan full of dirt/dust in the corner of the kitchen on the floor. A plastic bag of potatoes was observed under a prep table in the kitchen. The bag contained potatoes that were rotting and producing liquid (Photographic evidence obtained). An immediate interview was conducted with Staff A, Cook on [DATE] at 10:15 a.m. He said, those are baked potatoes. We just had those. He said he did not know why they were on the shelf. The bag was picked up and had liquid in the bottom. Staff V, RD picked up the bag and said uuuggghhh. The bag had no label or date. Additionally, a paper bag of uncooked potatoes was on the shelf. The bag was observed to have liquid leaking from it. The potatoes in the bag appeared rotten and wet. (Photographic evidence obtained) A mop bucket full of dark gray, dirty water with the mop sitting in it was observed. Staff F, Dietary Aide said she believed the water had been sitting there since the weekend, ,d+[DATE] days prior. Observations of the vent hood revealed storage of two cans of red beans and rice, a can of chicken noodle soup, a can of mackerel, coffee creamer, a portable speaker, and a hair clip. (Photographic evidence obtained) The lights and light cages located under the range hood was noted to be covered in dust. Additional observation revealed the convection oven was located under the range hood and was noted to have debris on top of the unit. During an interview on [DATE] at 10:16 AM with Staff A, cook, he reported the top of the convection oven was used to heat/raise bread and that he does not remember when it was last cleaned. Staff A reported a company comes in to clean the range hood but does not know when the vendor last came. Inspection of an orange sticker mounted on the left corner of the range hood revealed that the vendor last inspected the range hood on [DATE]. (Photographic evidence provided). Observation of the bottom of the prep table revealed an unlabeled, undated container of brown liquid. An interview was conducted immediately with Staff A, Cook. He said he did not know what was in the container or how long it had been there. (Photographic evidence obtained) A dry storage container containing salt was observed under the kitchen prep table, and a scoop was stored in the salt. The scoop was observed to remain in the salt on [DATE]. A follow-up interview was conducted on [DATE] at 11:33 a.m. with Staff V, RD. She confirmed the scoop should not have been stored down in the salt. (Photographic evidence obtained) Observation of the milk chest cooler revealed a buildup of ice and sour milk spilled in the bottom. The edges under the lid were also dirty and stained with miscellaneous food/debris. (Photographic evidence obtained) Observation of a vent in the dry storage room revealed dust, dirt, and bio growth on the surface. Review of the dish machine logs revealed the dish machine temperature and sanitation was last tested on [DATE]. The log showed the same numbers entered for wash temp, rinse temp, final rinse, and sanitizer PPM. The employee initials showed one person initialed the log every day for all 3 meals. An interview with the RD revealed the initials belonged to the ANHA. The log revealed she indicated she worked every day and checked the machine temperature for breakfast, lunch, and dinner. The log was noted blank (no entries) from [DATE] to [DATE]. Review of a coffee machine temperature log dated [DATE], showed the same employee (nursing home administrator) had signed the temperature logs every day from [DATE]th to [DATE]. The log was blank (no entries) from [DATE]th through [DATE]. Review of cleaning checklists revealed missing documentation and blank logs. An interview was conducted on [DATE] at 9:40 a.m. with Staff V, RD. She stated she worked at the facility full time. She stated she was not aware there were outdated and expired food in the kitchen. She stated she expected staff to discard old foods every three days, stating that is very basic. All kitchen employees should know that. She stated they had cleaning checklists, but it was hard to follow - up because they did not have enough staff. She stated the kitchen manager left about a month prior and the administration had contracted with a traveling CDM (certified dietary manager) to assist in managing the kitchen. An interview was conducted on [DATE] at 9:55 a.m. with Staff W, CDM. She stated she had started a week earlier. She stated she spent two days the week prior organizing the dry food storage. She stated she removed moldy bread and re-ordered fresh bread. She stated she noted the facility did not have hand washing bowls and chemicals, and she had notified the NHA (nursing home administrator). She stated she did not know the refrigerator was full of outdated food. She said, I would have taken care of it. I would expect the staff to throw out old food and clean the kitchen as scheduled. Staff W, CDM stated she was not aware the dish machine was not working, and that the freezer had a problem. Staff W, CDM said, our biggest problem was staffing. three staff members called out. There has been a call out every day which means many tasks are not attended. A second kitchen tour was conducted during lunch service on [DATE], which revealed: At 11:20 a.m. upon entering the kitchen a cart was noted to be out of the refrigerator near the serving area loaded with fruit plates and containing cottage cheese. At 11:50 a.m. Staff V, RD was observed taking holding food temperatures. The RD temped the first fruit plate and cottage cheese at 57.3 F. The RD removed a second fruit plate with cottage cheese and checked the temperature in multiple locations on the plate. This plate temped at 60 F. In an immediate interview Staff V, RD said the fruit plates with cottage cheese should be held at 41 F or lower. Staff V, RD was observed disposing of the two plates of fruit and cottage cheese she tested ; however, the remaining plates of fruit and cottage cheese from the same cart were observed being placed on trays and served at lunch. On [DATE] at 11:30 a.m. Staff A, Cook was observed rolling a cart which contained uncovered bread around the kitchen. He left the stove area and rolled the cart towards the dirty dishes area, then proceeded to the clean dish area. He then rolled the cart to the walk -in cooler and grabbed some milk and then rolled the cart back to the prep area. The bread was uncovered and exposed to the elements during this process. On [DATE] at 11:42 a.m. Staff A, Cook was observed going to the dirty pot sink and pulling out a dirty stainless-steel pot, lid, and food processor blade out of the sink. He turned the water on and ran it over the pot and blade. He picked up a silver scouring pad and squirted some sanitizer on it and appeared to clean the inside of the pot while running some water over the lid. He took the items to the prep table and placed the blade in the bowl and put it on the food processor base. The lid was visibly soiled with a brown/purple puree. Staff A, Cook then placed the dirty lid on the food processor and began to puree bread. An immediate interview was conducted with Staff A, Cook. While reviewing photographic evidence, he said, I didn't notice. Staff A, Cook was visibly frustrated; took the lid off and went to the sink to wash the lid. Staff A, Cook did not discard the contaminated food. He then placed the lid back on the bowl and continued making the pureed bread. Staff W, CDM was notified of the situation. She said the food should have been thrown out and started over. (Photographic evidence obtained.) On [DATE] at 12:01 p.m. Staff A, Cook was observed to be serving food on the tray line with no cover on his beard. Non disposable cups, bowls, fruit plates, and plate covers were being utilized for the lunch service. On [DATE] at 12:10 p.m. an interview was conducted with Staff B, Dietary Aide. Staff B, Dietary Aide said the lids and cups being used were washed in the dish machine that was not sanitizing. She said, yes, and they are dirty. They ain't clean. Staff B, Dietary Aide said they did not test the dishwasher chemicals this morning. She said, the same number just gets written every day. Continued observation starting at 12:15 p.m. revealed the first three trays that came off the line were checked for accuracy based on the meal tickets. The trays had been completed and placed on the cart for delivery prior to being checked. o Tray #1. The ticket listed BBQ riblet sandwich, oatmeal raisin cookies, chocolate pudding ,d+[DATE] cup with 2 tablespoons of whipped topping, pb&j (peanut butter and jelly) sandwich, apple juice, salt, and pepper. The tray did not contain pudding or a pb&j sandwich. (Photographic evidence obtained) o Tray #2. The ticket listed pureed riblet sandwich, pureed creamed corn, pureed fortified mashed potatoes, ,d+[DATE] cup pudding, ,d+[DATE] cup diet pudding, whole milk. The tray did not contain pudding, diet pudding or whole milk. This tray was labeled as an early tray with large portions and fortified. The tray contained regular portions. (Photographic evidence obtained) o Tray #3. The ticket listed Large Portions, BBQ riblet sandwich (1 ,d+[DATE] sand), corn cobette, macaroni salad, 2 cookies, tossed salad, dressing. The tray only had 1 sandwich, 1 corn cobette, pasta salad, and no tossed salad. Regular portions were served. (Photographic evidence obtained) An interview was conducted on [DATE] at 12:23 p.m. with Staff V, RD regarding the completed trays. Staff V, RD said Tray #1 should have had a peanut butter and jelly sandwich on it. She said the dietary aides did not have any made. Staff V, RD looked at Tray #2 and said they did not have any regular pudding, diet pudding or whole milk to give the resident. She confirmed the tray only had regular portions and should have been large portions. When asked what food was fortified, Staff V, RD said she did not know, and she would have to ask the cook. Staff A, Cook said the potatoes were fortified. Staff V, RD reviewed Tray #3 and said it should have been large portions, and she said they did not have tossed salad to put on the tray. She said the issues should have been caught on the line when they were plating the food. An observation was conducted in the dining room on [DATE] at 12:38 p.m. One resident had a plate of oranges with no other food. The resident said she had asked for oranges to go with her meal, but they only gave her oranges. The dining room aide present looked at the resident's tray ticket and confirmed she should have had a meal and oranges. An interview was conducted on [DATE] at 12:27 p.m. with the ANHA. She stated she had completed the dish machine temperature logs herself. When asked if she worked every day during all three meals for the entire month, she stated she only filled out logs. She confirmed she had not taken the temperatures nor tested the dish machine herself. The ANHA stated she had been tasked by the NHA to assist in the kitchen when the kitchen manager left. She stated she was in the kitchen daily and would clean out the refrigerators daily. She stated she did not know how they missed the expired foods, and confirmed the food found was outdated with some items dated [DATE]. The ANHA stated she did not have any training or education on managing a kitchen, or on food safety/sanitation. On [DATE] at 5:02 p.m., during a meal service kitchen tour, an observation was made of an employee's cell phone next to the clean plates and silverware as Staff D, Cook was about to start meal service. An open cup with drinking water was also noted next to the items. Staff D, Cook confirmed it was her cell phone and her drinking water. On [DATE] at 5:02 p.m., an observation was made of Staff E, Dietary Aide preparing desserts. On the food preparation table, a blue backpack was observed stored next to the clean dishes used for the desserts. Staff E, Dietary Aide confirmed it was her backpack and stated that was where she normally keeps it. An interview was conducted on [DATE] at 10:17 a.m. with the Director of Maintenance (DOM). He stated he did not know the freezer had any problems. He stated two weeks prior they had an issue with it and at the time the power had tripped. He stated he would contact an outside vendor to get it repaired. The DOM stated no one notified him there was a problem. An interview was conducted on [DATE] at 5:04 p.m. with Staff V, RD. She stated she never received a copy of the Job Description (JD), which the NHA provided to the survey team. She stated her duties were clinical and re-stated she was not responsible for kitchen operations. She stated she was not notified her duties included managing the kitchen or ensuring the kitchen was operational. A tour of the facility's three nourishment rooms was conducted on [DATE] from 10:30 a.m. to 11:00 a.m. Observation of the 4th floor nourishment room revealed: A bag of left-over food in the resident refrigerator dated [DATE], 55 days ago. Multiple left over plastic containers of food with no date. A cup of juice with no lid, resident label, or date. A Styrofoam container of left-over food dated [DATE], 11 days ago. (Photographic evidence obtained.) An interview with Staff L, RN/UM was conducted at that time. She said staff should all be cleaning out the refrigerator and items should be labeled with a resident name and date. Observation of the 3rd floor nourishment room revealed: Unlabeled half eaten container of store-bought potato salad. Undated plate of potato salad, undated to go containers, undated/unlabeled half-eaten pie. An unlabeled and undated open ice cream container (Photographic evidence obtained.) An interview was conducted with Staff G, RN/UM at that time. She said staff should be throwing out food that is old or not dated. She confirmed food should be labeled with a resident name and date it was put in the refrigerator. Observation of the 2nd floor nourishment room revealed: A 2-liter soda unlabeled and undated that was half empty. Lunch leftovers dated [DATE], 23 days ago. Gallon jug of sweet tea stamped by the manufacturer with good through [DATE]. Paper plate of food with aluminum foil in a plastic bag, unlabeled and undated Bowl of congealed unidentifiable substance, with no lid, and unlabeled and undated Ham sandwich in plastic wrap from ,d+[DATE] unlabeled Partially used Jug of grapefruit juice best by Aug. 29, 2023 (3 months past manufacture use or sell by date). Partially used Jug of grapefruit juice best by Jun 27, 2023, (5 months past manufacture use or sell by date). Medical ice packs with resident names in the freezer stored in conjunction with food. An interview was conducted at that time with Staff H, RN/UM. She said she did not know why the ice packs were there. The UM confirmed medical items should not be stored with food. She confirmed expired food should not be in the resident refrigerator and all food should be labeled with a resident name and date. On [DATE] at 12:20 p.m. an observation was made at lunch service of trays being served to residents in the dining room. Two trays were checked for accuracy based on the tray tickets. o Tray #1 listed grilled cheese, cottage cheese and chocolate milk. The tray only had a grilled cheese sandwich. An interview was conducted immediately with Resident #21. She said I just want the rest of my meal. I didn't get what I ordered. She added I guess they didn't think I was hungry. o Tray #2 listed chicken pot pie, fruit bowl, relish plate (renal), ,d+[DATE] bow tie pasta. The tray contained chicken pot pie, broccoli, a roll, and bowl of fruit. There was no relish plate and no bow tie pasta. A tour of the facility's kitchen on [DATE] starting at 9:25 a.m. revealed: A plastic bin with lid containing powdered thickener was observed below the prep table and the scoop was sitting on the prep table above the bin uncovered. A pressure washer was observed being stored in the dry food storage. Shelves in the clean dish area contained bowls and plates being stored in the upright position. A personal water bottle was sitting next to a stack of clean glasses on the drink fountain table. A drink pitcher with two inches of light-yellow unidentifiable liquid was in the reach in cooler with a sticker dated [DATE]. During an interview at 9:46 a.m. the RD said it was an old sticker that is not dissolvable in water and never got taken off. She said there should have been a new dissolvable sticker on the pitcher with the correct date. Review of Food Temperature Logs showed food temps were not taken for breakfast, lunch, or dinner on [DATE], dinner on [DATE], dinner on [DATE], breakfast or lunch on [DATE]. At 9:55 a.m. Staff A, Cook, confirmed the logbook was the only place food temperatures were documented. He looked at the book and confirmed no one did the food temperatures on the days listed. At 9:20 a.m. the dishwashing sink was observed clogged and being suctioned by staff with a wet vacuum. Once completed, the wet vacuum was stored under the counter where the clean dishes are set in racks to dry before storing. An observation at 9:38 a.m. revealed Staff S, Dietary Aide operating the dish machine. Interview with the dietary aide at this time revealed this was the third running of the dish machine since 9:30 a.m. During the observation Staff S, Dietary Aide was asked to test for sanitizer. The staff member was noted to use the test strips and dip it into the water that had remained at the bottom of the machine after the wash was complete. The test trip was noted to come out white in color. Continued interview with Staff S, Dietary aide at this time revealed this color meant the machine fell below the required 50-ppm reading of the test strip, and that it should read between ,d+[DATE]. The staff reported that this was a high temp dish machine. At this time Staff X, CDM interjected and verbalized that the machine is a low temp machine. An Interview was conducted with Staff X, CDM on [DATE] at 9:42 a.m. who revealed staff had run and checked the dish machine at the beginning of their shift and had documented the results on the dishwasher log hanging on the wall. Inspection of the dishwasher log at this time revealed that there was an entry dated ,d+[DATE] for breakfast where the sanitizer ppm was documented as 50 ppm. An interview was conducted on [DATE] at 9:45 a.m. with Staff E, Dietary Aide. She revealed she checked the dish machine around 7:00 a.m. and the sanitizer read 50 ppm. Staff E, Dietary Aide reported that if the ppm was less than 50, she would write it on the dish machine log. She reported there is nothing else to do other than to make sure she writes it down. During kitchen observations of the plating of the midday meal on [DATE] at 11:15 a.m. it was revealed that the staff were plating the meals using regular dishware. An interview with Staff T, RD on [DATE] at 11:20 a.m. revealed that the plates currently being used were the same plates that were washed in the morning. An interview on [DATE] at 11:23 a.m. with Staff S, Dietary Aide and Staff E, Dietary Aide revealed that none of the dishware that was washed in the morning was re-washed. During an observation on [DATE] from 11:29 a.m. to 11: 45 p.m. Staff X, CDM was asked to run the dish machine. The CDM was noted to test the ppm after the second cycle by dipping the test strips directly into the water settled on the bottom of the dish machine. The strip was noted to reveal a purple color which falls within the ,d+[DATE] ppm range. The CDM was asked to run the machine for a third cycle but to place the test strip on the surface of the plate. When tested the strip presented a faint purple color falling below the 50-ppm range. An interview on [DATE] at 11:33 a.m. with Staff X, CDM reported plating of the midday meal was in progress, but that she will now have them go to disposable plates. During observations of the tray line on [DATE] at 11:36 a.m. Staff A, Cook was observed to take food from 3 regular plates that had already been plated and transfer the food to the disposable plates. Staff X, CDM was notified immediately, and she directed the cook to discard the food that had been transferred from the regular plate. Continued observations on [DATE] at 11:47 a.m. revealed the tray line was in progress utilizing disposable plates to plate food. It was noted that regular silverware, cups, and bowls were being utilized. An interview with Staff T, RD at this time revealed that previous trays had been discarded but the current trays were being served. During an Interview on [DATE] at 11:52 a.m. with Staff X, CDM, NHA, Regional [NAME] President, and Regional Nurse Consultant, Staff X, CDM reported when she tested the sanitizer, the readings were inconsistent as the strips on two trials presented too light which means that the ppm was less than 50. She reported the plates were taken off-line, they went to paper, and the vendor had been called for a repair. The NHA reported staff were checking for the sanitizer and they know what to do. He reported the dish machine was checked and working this morning, but it just stopped working when the surveyor was present. Staff X, CDM reported at this time the eating utensils, cups and bowls can be used as they were washed last night. Staff X, CDM reported she can be sure the sanitizer was working last night, as the results were documented on the dish machine log. Review of the Dish machine log at this time revealed there was no entry for [DATE] dinner. Staff X, CDM reported based on the log she could not be sure that the dish machine was working the night prior. She confirmed when the sanitizer is not working, they should utilize paper goods. An interview was conducted on [DATE] 12:05 p.m. with Staff X, CDM. She said food temperatures should be taken every meal by the cook. She agreed they have no way of knowing if food was cooked properly and going out to residents if they are not checking the temperatures. An interview was conducted on [DATE] at 1:35 p.m. with the DON (Director of Nursing). The DON said she spoke with the facility's medical director about residents in the dining room being served today with utensils and bowls that had possibly not been cleaned properly. The medical director said he would like the residents to be monitored for two days for any gastrointestinal upset. The DON said they will be monitoring all residents who ate in the dining room at lunch today. On [DATE] at 11:55 a.m. an observation was made in the kitchen of a clean dish rack with bowls wet nested and the food surface facing upward. The top bowl was noted to have a light-brown liquid in it. An interview was conducted immediately with Staff X, CDM. She confirmed the dish rack was for clean dishes, the bowls should not be stacked when wet and they should be faced down. Upon further inspection she stated someone must have put something dirty on the top shelf that spilled through the rack onto the bowls and container underneath. An interview was conducted on [DATE] at 11:55 a.m. with the DON. The DON said she expected staff to follow the facility's policy regarding the nourishment rooms on each floor, including completing the temperature log and labeling all food with the resident's name and date. She said the unit managers and the ,d+[DATE] nurses are expected to check the refrigerators daily and she periodically checks them. <br[TRUNCATED]

Based on observations, interviews, and record review, the facility failed to utilize the Quality Assurance and Performance Improvement (QAPI) process to investigate, develop, and implement an effective Performance Improvement Plan (PIP) to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety in one of one kitchen observed, and three of three nutrition rooms observed. The facility failed to ensure the safety of 158 residents in the facility as a result of the failure. The likelihood of serious injury and/or death to 158 residents as a result of the facility's failure to prepare, store and serve food in accordance with professional standards for food service safety resulted in the determination of Immediate Jeopardy on [DATE]. The findings of Immediate Jeopardy were determined to be removed on [DATE] and the severity and scope was reduced to a D. Findings included: During a survey on [DATE] to [DATE] and [DATE] to [DATE] the following non-compliance was found. On [DATE] starting at 9:30 a.m. a tour of the facility's kitchen was conducted which revealed: An observation was made of kitchen floors and walls which appeared dirty and covered with miscellaneous food particles. (Photographic evidence obtained) The left side of the main reach-in refrigerator was observed with condensation and black bio-growth on the outside surface. The inside was noted with water on the floor of the refrigerator and food sitting in the pool of water. An immediate interview was conducted with Staff A, Cook on [DATE] at 9:32 a.m. He revealed the refrigerator had been leaking for some time and the facility's administration was aware. He stated it would have been at least 3 months. Observations during the kitchen tour of the inside of the main refrigerator also revealed expired and undated foods, and approximately 20 different food items/containers that could not be identified. Further investigation of the inside of the main refrigerator revealed: o One food container labeled rice which when opened revealed a foul/rancid odor. o An undated and unlabeled pasta salad with fuzzy, green bio growth, which was prepared by the facility kitchen staff and contained within a re-useable plastic container that was unlabeled and undated. o A half circle of unidentified meat (appeared to be unsliced cooked deli meat), undated and unlabeled, wrapped in plastic wrap (not original packaging) with use first sticker. o A large ham wrapped in plastic wrap (not original packaging) unlabeled and undated with use first sticker. o A container of black beans dated ,d+[DATE] in a reusable plastic container with lid (not original packaging). o A container of diced tomatoes dated ,d+[DATE] in a reusable plastic container with lid (not original packaging). o A container labeled garden noodles with black and white bio growth on the surface of the food, dated [DATE]. o An opened plastic tub of Pork base with no opened or use by date. A delivery sticker was dated [DATE]. An interview was conducted at the time of the observation on [DATE] at 9:57 a.m. with Staff V, RD. She looked at the pork base and said it should be good for a while but she did not know for how long or when it was opened. o All other observed food items/containers were unlabeled, undated, and the food items were unidentifiable. A second reach-in refrigerator was observed and revealed: o An unlabeled/undated container of unidentifiable food, with a use first label. An interview was conducted immediately with Staff F, Dietary Aide. Staff F, Dietary Aide said she believed it was peanut butter and jelly someone had mixed. (Photographic evidence obtained) o A bag of shredded carrots with a printed manufacturer date best if used by [DATE] (16 days past the manufacturer date). (Photographic evidence obtained) o A box of grape tomatoes with white bio-growth. (Photographic evidence obtained) A walk-in refrigerator was observed and revealed: o 2 bags of onions and peppers with a stamped date of [DATE] The 2 bags of onions and peppers were noted to be soft and partially liquefied. The liquid was leaking out of the bag and through the box onto the bread that packaging which was stored underneath. During an interview on [DATE] at 10:10 AM with the RD, she inspected the 2 bags of onion and peppers and reported she was unsure of the expiration date of the item and unsure how long the 2 bags of onion and peppers were in the walk-in refrigerator. (Photographic evidence provided) o A container of vanilla ice cream was observed on the shelf in the walk-in refrigerator. The container was soft to the touch. (Photographic evidence obtained.) o A bowl, plastic lid, butter, and an orange slice were observed on the floor under the walk-in refrigerator. (Photographic evidence obtained.) An observation of the Walk-in freezer revealed: o built-up ice and icicles on and around the 2 freezer vents mounted on the top rear of the freezer. o solid frozen icicles were noted to be enclosing a box of shredded pork, and a bag of mixed vegetables. During an interview on [DATE] at 10:12 AM, the RD reported she was not aware of the build-up of ice in the freezer, and it should have been reported to maintenance. (Photographic evidence provided) o trash and food on the floor under the shelves. (Photographic evidence obtained) o two open clear plastic bags of frozen meat patties in the freezer, not labeled or dated, and not in original box. (Photographic evidence obtained) An observation was made of a bucket with water dripping from the steamer. During an immediate interview, Staff A, Cook stated he did not know how long the water had been collecting in the bucket. (Photographic evidence obtained) The wall behind the juice machine was noted with dirt and debris on the surface. A large plastic container located next to the prep table was noted to be covered with a clear lid. Closer inspection revealed that the container contained a white powder that appeared to be flour which was noted to have brown/gray solid substances in the flour. During an interview with Staff V, Registered Dietician (RD) on [DATE] at 10:05 AM, she removed some of the solid substance from the plastic container and reported she did not know what the substance was, stating someone must have spilt something. Staff V, RD reported the flour should have been discarded. (Photographic evidence obtained). A clean pot rack was noted close to the 3-compartment sink. The rack was noted to have several pots and pans stored in the upward position instead of the food surface being facedown (Photographic evidence provided). Breakfast food items were observed on the countertop by the stove. The items included pancakes, French toast, and sausage wrapped in clear film wrap. An immediate interview with Staff A, Cook was conducted. He stated they were leftovers from breakfast, and he would be putting them away. At approximately 11:20 a.m. Staff A, Cook was observed taking the items to the walk-in cooler for storage. In an interview, Staff A, Cook confirmed the items had been sitting on the countertop by the stove for at least three hours, stating they would probably be out of the required temperature range. A tour of the dish machine area revealed floor surfaces with dirt, grime and food remains. During the tour, two dietary aides, Staff B and Staff C, were observed operating the dish washing machine. They were asked to test the machine's water temperature and chlorine sanitization levels. Staff B, Dietary Aide was observed conducting a water temperature and chemical sanitation test. The chemical test trip was observed as white, indicating the sanitization chemicals were not at appropriate levels. In an immediate interview, Staff B, Dietary Aide stated the test strip should be a light purple to a dark purple color, meaning 50 to 100 parts per million (PPM). Both aides confirmed the dish machine was not working. They stated the problem had been on- going and the machine worked on and off. The aide stated they believed Staff V, RD, and the assistant nursing home administrator (ANHA) were aware. An immediate follow -up was conducted with Staff W, Certified Dietary Manager (CDM.) She stated she did not know the machine was not working. She said, it appears we have a sanitization issue. The machine is not reaching the required PPM. She stated the PPM levels should be between 50 and 100 for the dishes to be considered sanitary. Further observation of the facility's dish machine revealed there was a white chalky substance noted on the top of the dish machine. Additionally, both the dirty and clean doors of the dish machine were noted to be coated with the white chalky substance. (Photographic evidence obtained) An observation was made of cleaning equipment and a dustpan full of dirt/dust in the corner of the kitchen on the floor. A plastic bag of potatoes was observed under a prep table in the kitchen. The bag contained potatoes that were rotting and producing liquid (Photographic evidence obtained). An immediate interview was conducted with Staff A, Cook on [DATE] at 10:15 a.m. He said, those are baked potatoes. We just had those. He said he did not know why they were on the shelf. The bag was picked up and had liquid in the bottom. Staff V, RD picked up the bag and said uuuggghhh. The bag had no label or date. Additionally, a paper bag of uncooked potatoes was on the shelf. The bag was observed to have liquid leaking from it. The potatoes in the bag appeared rotten and wet. (Photographic evidence obtained) A mop bucket full of dark gray, dirty water with the mop sitting in it was observed. Staff F, Dietary Aide said she believed the water had been sitting there since the weekend, ,d+[DATE] days prior. Observations of the vent hood revealed storage of two cans of red beans and rice, a can of chicken noodle soup, a can of mackerel, coffee creamer, a portable speaker, and a hair clip. (Photographic evidence obtained) The lights and light cages located under the range hood was noted to be covered in dust. Additional observation revealed the convection oven was located under the range hood and was noted to have debris on top of the unit. During an interview on [DATE] at 10:16 AM with Staff A, cook, he reported the top of the convection oven was used to heat/raise bread and that he does not remember when it was last cleaned. Staff A reported a company comes in to clean the range hood but does not know when the vendor last came. Inspection of an orange sticker mounted on the left corner of the range hood revealed that the vendor last inspected the range hood on [DATE]. (Photographic evidence provided). Observation of the bottom of the prep table revealed an unlabeled, undated container of brown liquid. An interview was conducted immediately with Staff A, Cook. He said he did not know what was in the container or how long it had been there. (Photographic evidence obtained) A dry storage container containing salt was observed under the kitchen prep table, and a scoop was stored in the salt. The scoop was observed to remain in the salt on [DATE]. A follow-up interview was conducted on [DATE] at 11:33 a.m. with Staff V, RD. She confirmed the scoop should not have been stored down in the salt. (Photographic evidence obtained) Observation of the milk chest cooler revealed a buildup of ice and sour milk spilled in the bottom. The edges under the lid were also dirty and stained with miscellaneous food/debris. (Photographic evidence obtained) Observation of a vent in the dry storage room revealed dust, dirt, and bio growth on the surface. Review of the dish machine logs revealed the dish machine temperature and sanitation was last tested on [DATE]. The log showed the same numbers entered for wash temp, rinse temp, final rinse, and sanitizer PPM. The employee initials showed one person initialed the log every day for all 3 meals. An interview with the RD revealed the initials belonged to the ANHA. The log revealed she indicated she worked every day and checked the machine temperature for breakfast, lunch, and dinner. The log was noted blank (no entries) from [DATE] to [DATE]. Review of a coffee machine temperature log dated [DATE], showed the same employee (nursing home administrator) had signed the temperature logs every day from [DATE]th to [DATE]. The log was blank (no entries) from [DATE]th through [DATE]. Review of cleaning checklists revealed missing documentation and blank logs. An interview was conducted on [DATE] at 9:40 a.m. with Staff V, RD. She stated she worked at the facility full time. She stated she was not aware there were outdated and expired food in the kitchen. She stated she expected staff to discard old foods every three days, stating that is very basic. All kitchen employees should know that. She stated they had cleaning checklists, but it was hard to follow - up because they did not have enough staff. She stated the kitchen manager left about a month prior and the administration had contracted with a traveling CDM (certified dietary manager) to assist in managing the kitchen. An interview was conducted on [DATE] at 9:50 a.m. with the Nursing Home Administrator (NHA) and Assistant Nursing Home Administrator (ANHA.) The NHA observed the expired and outdated cooked foods as Staff A, Cook placed them on a rolling cart. He stated they were in the process of making sure the kitchen is cleaned and maintained in a sanitary manner. He stated they had initiated a QAPI to address the issues in the kitchen. He stated the QAPI had been in place for 25 days. He stated he identified they had a problem because the staff lacked follow-through and that was why he had to let the kitchen manager go. He stated the ANHA had stepped in to assist with the day-to-day operations. He said, We will have all that food thrown out. We will clean it up. We would not serve that food to our residents. We have a QAPI in place. We are aware we have a problem and that is why I have a traveling Certified Dietary Manager (CDM) to help. The NHA was asked why the rotten food had not been thrown out immediately upon noticing an issue. He stated, it's a process and he had to give staff time to fix it. An interview was conducted on [DATE] at 9:55 a.m. with Staff W, CDM. She stated she had started a week earlier. She stated she spent two days the week prior organizing the dry food storage. She stated she removed moldy bread and re-ordered fresh bread. She stated she noted the facility did not have hand washing bowls and chemicals, and she had notified the NHA (nursing home administrator). She stated she did not know the refrigerator was full of outdated food. She said, I would have taken care of it. I would expect the staff to throw out old food and clean the kitchen as scheduled. Staff W, CDM stated she was not aware the dish machine was not working, and that the freezer had a problem. Staff W, CDM said, our biggest problem was staffing. three staff members called out. There has been a call out every day which means many tasks are not attended. A second kitchen tour was conducted during lunch service on [DATE], which revealed: At 11:20 a.m. upon entering the kitchen a cart was noted to be out of the refrigerator near the serving area loaded with fruit plates and containing cottage cheese. At 11:50 a.m. Staff V, RD was observed taking holding food temperatures. The RD temped the first fruit plate and cottage cheese at 57.3 F. The RD removed a second fruit plate with cottage cheese and checked the temperature in multiple locations on the plate. This plate temped at 60 F. In an immediate interview Staff V, RD said the fruit plates with cottage cheese should be held at 41 F or lower. Staff V, RD was observed disposing of the two plates of fruit and cottage cheese she tested ; however, the remaining plates of fruit and cottage cheese from the same cart were observed being placed on trays and served at lunch. On [DATE] at 11:30 a.m. Staff A, Cook was observed rolling a cart which contained uncovered bread around the kitchen. He left the stove area and rolled the cart towards the dirty dishes area, then proceeded to the clean dish area. He then rolled the cart to the walk -in cooler and grabbed some milk and then rolled the cart back to the prep area. The bread was uncovered and exposed to the elements during this process. On [DATE] at 11:42 a.m. Staff A, Cook was observed going to the dirty pot sink and pulling out a dirty stainless-steel pot, lid, and food processor blade out of the sink. He turned the water on and ran it over the pot and blade. He picked up a silver scouring pad and squirted some sanitizer on it and appeared to clean the inside of the pot while running some water over the lid. He took the items to the prep table and placed the blade in the bowl and put it on the food processor base. The lid was visibly soiled with a brown/purple puree. Staff A, Cook then placed the dirty lid on the food processor and began to puree bread. An immediate interview was conducted with Staff A, Cook. While reviewing photographic evidence, he said, I didn't notice. Staff A, Cook was visibly frustrated; took the lid off and went to the sink to wash the lid. Staff A, Cook did not discard the contaminated food. He then placed the lid back on the bowl and continued making the pureed bread. Staff W, CDM was notified of the situation. She said the food should have been thrown out and started over. (Photographic evidence obtained.) On [DATE] at 12:01 p.m. Staff A, Cook was observed to be serving food on the tray line with no cover on his beard. Non disposable cups, bowls, fruit plates, and plate covers were being utilized for the lunch service. On [DATE] at 12:10 p.m. an interview was conducted with Staff B, Dietary Aide. Staff B, Dietary Aide said the lids and cups being used were washed in the dish machine that was not sanitizing. She said, yes, and they are dirty. They ain't clean. Staff B, Dietary Aide said they did not test the dishwasher chemicals this morning. She said, the same number just gets written every day. Continued observation starting at 12:15 p.m. revealed the first three trays that came off the line were checked for accuracy based on the meal tickets. The trays had been completed and placed on the cart for delivery prior to being checked. o Tray #1. The ticket listed BBQ riblet sandwich, oatmeal raisin cookies, chocolate pudding ,d+[DATE] cup with 2 tablespoons of whipped topping, pb&j (peanut butter and jelly) sandwich, apple juice, salt, and pepper. The tray did not contain pudding or a pb&j sandwich. (Photographic evidence obtained) o Tray #2. The ticket listed pureed riblet sandwich, pureed creamed corn, pureed fortified mashed potatoes, ,d+[DATE] cup pudding, ,d+[DATE] cup diet pudding, whole milk. The tray did not contain pudding, diet pudding or whole milk. This tray was labeled as an early tray with large portions and fortified. The tray contained regular portions. (Photographic evidence obtained) o Tray #3. The ticket listed Large Portions, BBQ riblet sandwich (1 ,d+[DATE] sand), corn cobette, macaroni salad, 2 cookies, tossed salad, dressing. The tray only had 1 sandwich, 1 corn cobette, pasta salad, and no tossed salad. Regular portions were served. (Photographic evidence obtained) An interview was conducted on [DATE] at 12:23 p.m. with Staff V, RD regarding the completed trays. Staff V, RD said Tray #1 should have had a peanut butter and jelly sandwich on it. She said the dietary aides did not have any made. Staff V, RD looked at Tray #2 and said they did not have any regular pudding, diet pudding or whole milk to give the resident. She confirmed the tray only had regular portions and should have been large portions. When asked what food was fortified, Staff V, RD said she did not know, and she would have to ask the cook. Staff A, Cook said the potatoes were fortified. Staff V, RD reviewed Tray #3 and said it should have been large portions, and she said they did not have tossed salad to put on the tray. She said the issues should have been caught on the line when they were plating the food. An observation was conducted in the dining room on [DATE] at 12:38 p.m. One resident had a plate of oranges with no other food. The resident said she had asked for oranges to go with her meal, but they only gave her oranges. The dining room aide present looked at the resident's tray ticket and confirmed she should have had a meal and oranges. An interview was conducted on [DATE] at 12:27 p.m. with the ANHA. She stated she had completed the dish machine temperature logs herself. When asked if she worked every day during all three meals for the entire month, she stated she only filled out logs. She confirmed she had not taken the temperatures nor tested the dish machine herself. The ANHA stated she had been tasked by the NHA to assist in the kitchen when the kitchen manager left. She stated she was in the kitchen daily and would clean out the refrigerators daily. She stated she did not know how they missed the expired foods, and confirmed the food found was outdated with some items dated [DATE]. The ANHA stated she did not have any training or education on managing a kitchen, or on food safety/sanitation. On [DATE] at 5:02 p.m., during a meal service kitchen tour, an observation was made of an employee's cell phone next to the clean plates and silverware as Staff D, Cook was about to start meal service. An open cup with drinking water was also noted next to the items. Staff D, Cook confirmed it was her cell phone and her drinking water. On [DATE] at 5:02 p.m., an observation was made of Staff E, Dietary Aide preparing desserts. On the food preparation table, a blue backpack was observed stored next to the clean dishes used for the desserts. Staff E, Dietary Aide confirmed it was her backpack and stated that was where she normally keeps it. An interview was conducted on [DATE] at 10:17 a.m. with the Director of Maintenance (DOM). He stated he did not know the freezer had any problems. He stated two weeks prior they had an issue with it and at the time the power had tripped. He stated he would contact an outside vendor to get it repaired. The DOM stated no one notified him there was a problem. An interview was conducted on [DATE] at 5:04 p.m. with Staff V, RD. She stated she never received a copy of the Job Description (JD), which the NHA provided to the surveyor team. She stated her duties were clinical and re-stated she was not responsible for kitchen operations. She stated she was not notified her duties included managing the kitchen or ensuring the kitchen was operational. A tour of the facility's three nourishment rooms was conducted on [DATE] from 10:30 a.m. to 11:00 a.m. Observation of the 4th floor nourishment room revealed: o A bag of left-over food in the resident refrigerator dated [DATE], 55 days ago. o Multiple left over plastic containers of food with no date. o A cup of juice with no lid, resident label, or date. o A Styrofoam container of left-over food dated [DATE], 11 days ago. (Photographic evidence obtained.) An interview with Staff L, RN/UM was conducted at that time. She said staff should all be cleaning out the refrigerator and items should be labeled with a resident name and date. Observation of the 3rd floor nourishment room revealed: o Unlabeled half eaten container of store-bought potato salad. o Undated plate of potato salad, undated to go containers, undated/unlabeled half-eaten pie. o An unlabeled and undated open ice cream container (Photographic evidence obtained.) An interview was conducted with Staff G, RN/UM at that time. She said staff should be throwing out food that is old or not dated. She confirmed food should be labeled with a resident name and date it was put in the refrigerator. Observation of the 2nd floor nourishment room revealed: o A 2-liter soda unlabeled and undated that was half empty. o Lunch leftovers dated [DATE], 23 days ago. o Gallon jug of sweet tea stamped by the manufacturer with good through [DATE]. o Paper plate of food with aluminum foil in a plastic bag, unlabeled and undated o Bowl of congealed unidentifiable substance, with no lid, and unlabeled and undated o Ham sandwich in plastic wrap from ,d+[DATE] unlabeled o Partially used Jug of grapefruit juice best by Aug. 29, 2023 (3 months past manufacture use or sell by date). o Partially used Jug of grapefruit juice best by Jun 27, 2023, (5 months past manufacture use or sell by date). o Medical ice packs with resident names in the freezer stored in conjunction with food. An interview was conducted at that time with Staff H, RN/UM. She said she did not know why the ice packs were there. The UM confirmed medical items should not be stored with food. She confirmed expired food should not be in the resident refrigerator and all food should be labeled with a resident name and date. On [DATE] at 12:20 p.m. an observation was made at lunch service of trays being served to residents in the dining room. Two trays were checked for accuracy based on the tray tickets. o Tray #1 listed grilled cheese, cottage cheese and chocolate milk. The tray only had a grilled cheese sandwich. An interview was conducted immediately with Resident #21. She said I just want the rest of my meal. I didn't get what I ordered. She added I guess they didn't think I was hungry. o Tray #2 listed chicken pot pie, fruit bowl, relish plate (renal), ,d+[DATE] bow tie pasta. The tray contained chicken pot pie, broccoli, a roll, and bowl of fruit. There was no relish plate and no bow tie pasta. A tour of the facility's kitchen on [DATE] starting at 9:25 a.m. revealed: o A plastic bin with lid containing powdered thickener was observed below the prep table and the scoop was sitting on the prep table above the bin uncovered. o A pressure washer was observed being stored in the dry food storage. o Shelves in the clean dish area contained bowls and plates being stored in the upright position. o A personal water bottle was sitting next to a stack of clean glasses on the drink fountain table. o A drink pitcher with two inches of light-yellow unidentifiable liquid was in the reach in cooler with a sticker dated [DATE]. During an interview at 9:46 a.m. the RD said it was an old sticker that is not dissolvable in water and never got taken off. She said there should have been a new dissolvable sticker on the pitcher with the correct date. o Review of Food Temperature Logs showed food temps were not taken for breakfast, lunch, or dinner on [DATE], dinner on [DATE], dinner on [DATE], breakfast or lunch on [DATE]. At 9:55 a.m. Staff A, Cook, confirmed the logbook was the only place food temperatures were documented. He looked at the book and confirmed no one did the food temperatures on the days listed. o At 9:20 a.m. the dishwashing sink was observed clogged and being suctioned by staff with a wet vacuum. Once completed, the wet vacuum was stored under the counter where the clean dishes are set in racks to dry before storing. o An observation at 9:38 a.m. revealed Staff S, Dietary Aide operating the dish machine. Interview with the dietary aide at this time revealed this was the third running of the dish machine since 9:30 a.m. During the observation Staff S, Dietary Aide was asked to test for sanitizer. The staff member was noted to use the test strips and dip it into the water that had remained at the bottom of the machine after the wash was complete. The test trip was noted to come out white in color. Continued interview with Staff S, Dietary aide at this time revealed this color meant the machine fell below the required 50-ppm reading of the test strip, and that it should read between ,d+[DATE]. The staff reported that this was a high temp dish machine. At this time Staff X, CDM interjected and verbalized that the machine is a low temp machine. An Interview was conducted with Staff X, CDM on [DATE] at 9:42 a.m. who revealed staff had run and checked the dish machine at the beginning of their shift and had documented the results on the dishwasher log hanging on the wall. Inspection of the dishwasher log at this time revealed that there was an entry dated ,d+[DATE] for breakfast where the sanitizer ppm was documented as 50 ppm. An interview was conducted on [DATE] at 9:45 a.m. with Staff E, Dietary Aide. She revealed she checked the dish machine around 7:00 a.m. and the sanitizer read 50 ppm. Staff E, Dietary Aide reported that if the ppm was less than 50, she would write it on the dish machine log. She reported there is nothing else to do other than to make sure she writes it down. During kitchen observations of the plating of the midday meal on [DATE] at 11:15 a.m. it was revealed that the staff were plating the meals using regular dishware. An interview with Staff T, RD on [DATE] at 11:20 a.m. revealed that the plates currently being used were the same plates that were washed in the morning. An interview on [DATE] at 11:23 a.m. with Staff S, Dietary Aide and Staff E, Dietary Aide revealed that none of the dishware that was washed in the morning was re-washed. During an observation on [DATE] from 11:29 a.m. to 11: 45 p.m. Staff X, CDM was asked to run the dish machine. The CDM was noted to test the ppm after the second cycle by dipping the test strips directly into the water settled on the bottom of the dish machine. The strip was noted to reveal a purple color which falls within the ,d+[DATE] ppm range. The CDM was asked to run the machine for a third cycle but to place the test strip on the surface of the plate. When tested the strip presented a faint purple color falling below the 50-ppm range. An interview on [DATE] at 11:33 a.m. with Staff X, CDM reported plating of the midday meal was in progress, but that she will now have them go to disposable plates. During observations of the tray line on [DATE] at 11:36 a.m. Staff A, Cook was observed to take food from 3 regular plates that had already been plated and transfer the food to the disposable plates. Staff X, CDM was notified immediately, and she directed the cook to discard the food that had been transferred from the regular plate. Continued observations on [DATE] at 11:47 a.m. revealed the tray line was in progress utilizing disposable plates to plate food. It was noted that regular silverware, cups, and bowls were being utilized. An interview with Staff T, RD at this time revealed that previous trays had been discarded but the current trays were being served. During an Interview on [DATE] at 11:52 a.m. with Staff X, CDM, NHA, Regional [NAME] President, and Regional Nurse Consultant, Staff X, CDM reported when she tested the sanitizer, the readings were inconsistent as the strips on two trials presented too light which means that the ppm was less than 50. She reported the plates were taken off-line, they went to paper, and the vendor had been called for a repair. The NHA reported staff were checking for the sanitizer and they know what to do. He reported the dish machine was checked and working this morning, but it just stopped working when the surveyor was present. Staff X, CDM reported at this time the eating utensils, cups and bowls can be used as they were washed last night. Staff X, CDM reported she can be sure the sanitizer was working last night, as the results were documented on the dish machine log. Review of the Dish machine log at this time revealed there was no entry for [DATE] dinner. Staff X, CDM reported based on the log she could not be sure that the dish machine was working the night prior. She confirmed when the sanitizer is not working, they should utilize paper goods. An interview was conducted on [DATE] 12:05 p.m. with Staff X, CDM. She said food temperatures should be taken every meal by the cook. She agreed they have no way of knowing if food was cooked properly and going out to residents if they are not checking the temperatures. An interview was conducted on [DATE] at 1:35 p.m. with the DON (Director of Nursing). The DON said she spoke with the facility's medical director about residents [TRUNCATED]

Based on observations, interviews, record review and policy review, the facility failed to ensure pain medication was administered and pain was managed for three residents (#20, #14, and #9) of four reviewed for pain management. Findings included: 1. An interview was conducted on 11/29/23 at 3:18 p.m. with Resident #14. The resident stated her pain level was an 8 out of 10 on the pain scale and was located in her shoulders and lower back. The resident was lying in bed with the head of her bed elevated. She winced (shrinking movement of the body in anticipation of pain or distress) with pain when she tried to reposition herself. The resident said she has Morphine scheduled every 6 hours as needed and she routinely takes it two to three times a day. Resident #14 said it had been a couple of days since the facility had any available. She said she asked her nurse for pain medication two times that day and had been told her pain medication had not been delivered to the facility. The resident said she is worried because her pain is getting worse, and she will start having withdrawal symptoms from not having it as well. She said typically her stomach will begin hurting when she starts having withdrawal symptoms. Resident #14 said it would have helped if the nurse even gave her something that wasn't as strong to lower the pain. Review of admission records showed Resident #14 was admitted on [DATE] with diagnoses including cerebrovascular disease, muscle wasting and atrophy, history of falling, demyelinating disease of central nervous system, migraine, chronic pain, osteoarthritis, spondylosis with myelopathy in cervical region, spinal stenosis, cervical disc degeneration, and fibromyalgia. Review of Resident #14's Admission/Medicare 5 Day Minimum Data Set (MDS,) dated 11/22/23, Section C, Cognitive Patterns, showed her Brief Interview for Mental Status (BIMS) Score was 15, indicating she had intact cognition. Review of physician orders showed: -Acetaminophen tablet 325mg. Give 2 tablets by mouth every 6 hours as needed (PRN) for pain. Date 11/19/23. -Morphine Sulfate oral tablet 15mg. Give 1 tablet by mouth every 6 hours as needed for pain. Date 11/19/23. Review of Resident #14's Medication Administration Record (MAR) showed the resident did not receive any doses of Acetaminophen PRN for pain from 11/19/23 through 11/29/23 and did not received Morphine Sulfate between 11/22/23 at 4:55 p.m. and 11/29/23. Review of Nursing Progress note revealed a note dated 11/25/23 at 1:54 p.m. showing, Resident's tab Morphine is not in the [medication] cart. Called pharmacy. Pharmacy need a new prescription. Messaged the APRN [advanced practice registered nurse]. Waiting for response. Review of a care plan for Resident #14 showed a focus for pain or potential for pain, dated 10/18/23. Interventions included administer pain medication and observe for effectiveness, observe/anticipate the residents need for pain relief and offer/provide pain treatment/intervention, observe and report signs and symptoms of pain and worsening pain. Report changes in pain location/type frequency/intensity, notify/review with physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain. An interview was conducted on 11/29/23 at 3:05 p.m. with Staff I, RN. Staff I, RN said the facility had issues with the pharmacy not delivering until later in the day and some nurses do not hit reorder in the electronic health record (EHR). She said this is not the first time for Resident #14. Staff I, RN said when nurses call the pharmacy, the pharmacy will say they need a new prescription, then the nurse calls the doctor, and the doctor will say they want to evaluate the resident before giving a new prescription. Staff I, RN confirmed she did not call Resident #14's physician about the unavailability of her pain medication. Review of Progress notes did not show any notes related to the resident's pain, unavailability of medication, or notifying the provider of the resident's pain on 11/29/23. An interview was conducted on 11/29/23 at 4:22 p.m. with Staff J, RN. Staff J, RN said he took over care of Resident #14 at 3:00 p.m. He said he was not aware she had pain concerns today. Staff J, RN checked the orders for Resident #14 and confirmed she had an order for Morphine Sulfate. He was observed checking the medication cart and confirmed the resident did not have any Morphine Sulfate in the cart. Staff J, RN was observed going to Resident #14's room and asking her about pain. The resident told him her pain level was 8 out of 10 at that time and her stomach was hurting. The resident said sleep had been affected last night because she was in pain. An interview was conducted on 11/29/23 at 4:28 p.m. with Staff L, RN/Unit Manager (UM.) Staff L, RN/UM said there was no reason Resident #14 should not have had pain medication if. She said she had not been notified of Resident #14 needing medication, which was unavailable. Staff L, RN/UM said she would have expected the nurse to come tell her the problem or call the pharmacy herself. She said a code could have been given to the nurse to get the Morphine Sulfate out of the emergency drug kit (EDK) or the pharmacy could have sent the medication to the facility via a stat delivery. Staff L, RN/UM said the pharmacy typically delivers around 4-6 p.m. and then again 4-6 a.m., but they can send stat medications over within two hours. An interview was conducted on 11/29/23 at 4:59 p.m. with Staff P, Assistant Director of Nursing (ADON.) The ADON said if a resident is in pain and out of pain medication, she would expect the nurse to look and see if there are any alternate pain medications that could be given. She would then expect them to call the pharmacy. The ADON said the main concern is to get the resident out of pain. She said the nurse should find out from the pharmacy what the delay is and inform the doctor about the situation. She said No! it is not acceptable for Resident #14 to have not received pain medication after notifying her nurse multiple times she was in pain. The facility's pharmacy documentation provided by the ADON showed the pharmacy team delivers medications to the facility daily at 3:30 a.m., 1:00 p.m., and 7:30 p.m. A review of the pharmacy documents showed Resident #14 had a hospital prescription dated 11/17/23 for 5 tablets of Morphine Sulfate. The pharmacy documents showed 4 tablets of Morphine Sulfate for Resident #14 was delivered to the facility on [DATE]. A prescription was written for 60 doses of Morphine Sulfate on 11/28/23. 49227 2. Review of Resident #20's admission record revealed Resident #20 was admitted to the facility on [DATE] with diagnoses including neuropathy, chronic pain syndrome, osteomyelitis, and neuritis. Review of Resident #20's admission Minimum Data Set (MDS), dated [DATE], Section C - Cognitive Status, revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating Resident #20 was cognitively intact. Review of Resident #20's physician's orders revealed orders, dated 11/28/2023: 1) oxycodone-acetaminophen (Percocet) 10 milligrams (mg)-325 mg by mouth every six hours as needed (PRN) for pain. 2) Monitor pain on right foot, first toe amputation, every shift and record pain number on a 0-10 scale [0 is no Pain, 10 is the worst pain] for pain monitoring. An interview was conducted on 12/11/2023 at 1:54 p.m. with Resident #20. He reported his pain medication was only effective for a couple of hours, then the severe pain returns. The resident told the facility staff about the persistent pain two to three hours after receiving pain medication. Resident #20 said facility staff told him the pain management team would evaluate him and adjust pain medications. Resident #20 said he always requests his pain medication when he knows it is time for another dose. He said the intense pain has impacted his physical and occupational therapy treatments and have missed treatments scheduled to be completed in the therapy department. Review of Resident #20's progress notes revealed: -11/29/2023 note authored by the resident's primary care physician (PCP), revealed an order for consultation with pain management for Resident #20. -12/01/2023 at 10:45 a.m. revealed Resident #20 requested pain medications to be administered every four hours rather than six hours, the resident was informed by his assigned nurse the Medical Doctor (MD) was notified, the pain medication dose was increased already and the frequency would remain every six hours. -12/11/2023 at 2:12 p.m. pain assessment revealed Resident #20 said he has a 10 of 10 pain level on this [his] foot. The pain management doctor will visit him on 12/12 and his PCP was notified and ordered Ibuprofen 600mg (milligrams) every 4hrs for breakthrough pain. The resident was notified. Review of Resident #20's physical therapy (PT) plan of care, dated 11/29/2023 at 9:38 a.m. revealed the resident has good rehabilitation potential with plans for physical therapy five times per week for six weeks. A PT treatment note, dated 11/29/23 at 4:36 p.m. Resident #20 complains of excruciating pain, current pain intensity obstructs the resident from meeting full potential during functional mobilities/ transfers activities. PT documentation revealed the following. -12/03/23 Resident #20 ambulated 16 feet with the roller walker -12/07/23 ambulated up to 90 feet with the roller walker. -12/10/2023 Resident #20 did not walk and PT note revealed the resident was agreeable to treatment while supine (laying on his back) due to pain. -12/11/2023 Resident #20 was agreeable to therapy but declined to stand due to pain. Review of Resident # 20's occupational therapy (OT) treatment note documentation, dated 12/10/23 at 1:47 p.m. revealed resident presented with increased through RLE [right lower extremity], [resident] refused all out of bed activities today. Therapist reported [Resident #20] increase BLE (bilateral lower extremity) [pain] to nursing. Review of Resident #20 Care Plan initiated 11/29/23 revealed: -Focus related to pain with -Goals to include, resident will not experience a decline in overall function related to pain. -Interventions to include, 1)encourage the resident to inform the nurse of pain and the effectiveness of the interventions, 2) observe/anticipate the resident's need for pain relief and offer/provide pain treatment / intervention, 3) notify the physicians if interventions are unsuccessful. An additional intervention dated 12/12/2023 showed Pain Management consult/follow up per order and/or recommendations. A review of the Medication Administration Record (MAR) for December 2023 showed: -day shift pain level row 5 of 10 is documented on 12/1, 12/4, 12/5, 12/8 and 12/9. -evening shift pain level row on 12/6 pain level is 8 out of 10 other entries are 0 of 10, indicating no pain. -night shift pain level row, 0 of 10 is documented daily, indicating no pain. Review of Percocet order revealed: -12/1/2023 Percocet was administered once at 8:03 p.m. -12/5/2023-12/7/2023 Resident #20 received three of the four allotted dosages in a 24-hour period and the pain level was not documented. An interview was conducted on 12/13/2023 at 1:49 p.m. with Staff K, Registered Nurse (RN). Staff K, RN said she was assigned to Resident #20 during the 7:00 a.m. to 3:00 p.m. shift on 12/13/2023 and had taken care of the resident, several times before. Staff K, RN said Resident #20 always has pain and his pain medications lasts two to four hours. The unit manager (UM) has notified the pain management team about the consultation for Resident #20. Staff K, RN said Resident #20 always asks for PRN Percocet when it is due [every 6 hours]. A telephone interview was conducted on 12/12/2023 at 2:05 p.m. with Resident #20's Primary Care Physician (PCP), who said he the pain management team comes to the facility on Tuesdays. Resident #20's PCP said he expected the pain management team to evaluate the resident on the following Tuesday [12/5/23] after the consultation was ordered. An interview was conducted on 12/11/23 at 1:37 p.m. with the Director of Nursing (DON), who said the pain management team visits the facility every two weeks, on Tuesdays. For residents with persistent pain the resident's nurse is expected to assess the resident and contact the PCP and/or the pain management team, and/or the facility's medical director. All communication should be documented in the medical record. The DON stated it should not take three weeks for a pain management consultation to be completed. The DON confirmed the Referral Services policy applies to the pain team consultation. An interview was conducted on 12/13/2023 at 12:00 p.m. with Staff L, RN, Unit Manager, (UM). The UM said when a pain team consultation is ordered for a resident, the Unit Manager will add assign the pain team provider to the resident's profile. Staff L RN, UM said this gives the provider remote access to the resident's medical record and when the provider obtains a report from the electronic health record (EHR) the resident's name will be included. In reference to Resident #20's pain team consult Staff L RN, UM said on 11/29/2023, she texted the physician notification of the new admission and request the resident needed to be seen. She said there was a delay,as the physician was on vacation. 40775 3. A review of Resident #9's medical record revealed resident #9 was admitted to the facility on [DATE] with diagnoses of fibromyalgia and type II diabetes mellitus. A review of Resident #9's physician's orders revealed an order, dated 9/11/2023 for hydrocodone-acetaminophen (Norco) 5 milligrams (mg)-325 mg by mouth every four hours as needed (PRN) for pain. A review of Resident #9's progress notes, dated on 11/23/2023 at 5:40 PM and authored by Staff Q, Registered Nurse (RN), revealed Resident #9 was complaining of pain and requested her PRN Norco, but did not have any medication remaining. Staff Q, RN contacted Resident #9's physician and the pharmacy regarding the medication and explained to Resident #9 the medication would be delivered to the facility on the next pharmacy run. A review of Resident #9's progress notes, dated on 11/23/2023 10:02 PM and authored by Staff Q, RN, revealed Resident #9 called 911 to have herself transported to the hospital due to not having her pain medication available. Emergency medical services (EMS) arrived to the facility and transported Resident #9 to the hospital. An interview was conducted on 11/28/2023 at 2:00 PM with Resident #9 inside of the resident's room. Resident #9 stated her pain medication would run out frequently due to her pain management doctor going on vacation and not ensuring the prescription is filled before he leaves. Resident #9 also stated she did not receive her PRN Norco on 11/23/2023 because the medication ran out. A review of Resident #9's Annual Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 9/14/2023 revealed under Section C - Cognitive Status, a Brief Interview for Mental Status (BIMS) score of 13, indicating Resident #9 was cognitively intact. An interview was conducted on 11/29/2023 at 11:37 AM with Staff Q, RN. Staff Q, RN stated she was Resident #9's assigned nurse for the 3 PM to 11 PM shift on 11/23/2023 and was assigned Resident #9 about three times a week. Staff Q, RN also stated Resident #9 would frequently ask for her PRN Norco due to complaints of pain. Staff Q, RN stated she discovered Resident #9 was out of her PRN Norco when she arrived on her shift on 11/23/2023 at 3 PM and made a call to the pharmacy around 3:30 PM to get more of the medication. Staff Q, RN also called Resident #9's physician to obtain a new prescription for Resident #9's pain medication. The physician told Staff Q, RN they would fax a new prescription to the pharmacy. Staff Q, RN told Resident #9 the pain medication would be delivered later on that evening. Staff Q, RN stated around 5 or 6 PM, Resident #9 told her she was having nausea and needed her pain medication. Staff Q, RN stated Resident #9 was acting up due to not having her pain medication. Staff Q, RN stated around 10 PM, EMS staff arrived to the facility to take Resident #9 to the hospital. Resident #9 called 911 herself without Staff Q, RN's knowledge and was not aware Resident #9 wanted to go to the hospital until EMS arrived to the facility. Resident #9 was taken to the hospital and did not return by the end of Staff Q, RN's shift at 11 PM. Staff Q, RN stated she would normally ensure resident's have 4 or 5 days of their medications left and if the resident has less than that they are to call the pharmacy for a refill. Staff Q, RN also stated the facility did not have a protocol in place to obtain a one time dose of the medication. An interview was conducted on 11/29/2023 at 2:09 PM with Staff P, Assistant Director of Nursing (ADON). Staff P, ADON stated to reorder resident's medications, nursing staff can select the reorder button in the electronic health record. The pharmacy would call the facility if a new prescription was needed for the medication to fill it and the nurse would call the resident's physician to ensure the physician sends the prescription to the pharmacy. Once the prescription is obtained from the pharmacy, the pharmacy can provide the nurse with a code so it can be obtained from the facility's emergency drug kit (EDK) if needed. Staff P, ADON stated medications should be reordered two days before the resident runs out completely. Staff P, ADON also stated she would not expect the nursing staff to wait until a medication was completely out before reordering it. A review of the facility policy titled Controlled Substance Medication Orders, effective in May of 2016, revealed under the section titled Policy, before a controlled substance medication can be dispensed, the pharmacy must be in receipt of a clear, complete, valid prescription from a person lawfully authorized to prescribe them. The pharmacy can dispense a Schedule II controlled substance medication only after the receipt of a practitioner signed valid Schedule II prescription or in the case of an emergency, the practitioner may speak directly to the pharmacist providing an emergency authorization for the pharmacy to supply a small quantity of the Schedule II medication until the practitioner can provide a valid signed prescription. The policy also revealed under the section titled Procedure, the pharmacist can receive a verbal emergency authorization for Schedule II controlled medications if communicated directly to the pharmacist by the prescriber. If a verbal authorization is received by the pharmacist, the pharmacist will contact the facility nurse. If the controlled substance is needed as an emergency, the pharmacist may provide authorization to the nurse to access the controlled substance from the emergency supply located in the facility. A review of the facility's listing of emergency drugs in the EDK revealed Norco 5 mg-325 mg, morphine immediate release 15 mg, and morphine sustained release 15 mg were available in the facility's EDK. Review of a facility-provided policy titled Pain Management, dated October 2021 showed: Overview: The team will encourage the resident/patient and family to report pain since the longer pain goes untreated, the harder it is to relieve. Guidelines: 4a. Assure the resident/patient that pain can be managed effectively. b. Identify any unrealistic expectations of the resident/patient and/or family. c. Elicit the resident/patient's feelings and thoughts regarding fear of pain. d. Encourage the resident/patient tq be an active participant in their own pain management. 6e. Maintain prescribed levels. Ensure medications are taken on time even if asymptomatic unless ordered PRN. 8 Obtain an order for around-the-clock dosing if the following occurs: - Duration of pain relief/control is consistently less than the dosing interval. - Pain is not well controlled. - Pain management requires three or more doses for breakthrough pain per day. 11. Keep resident/patient and family informed, knowledgeable, and in control of pain management. 12. Re-evaluate pain status frequently. 13. Review and revise the Plan of [NAME] as needed to relieve /control pain. Review of a facility-provided policy titled Ordering adn Receiving Controlled Medications, dated 2007 showed: 5. Refill Requests for CJJI-CV, and Partial Fill Requests for CII a. If one or more refills (CIII-Vs) or a partial fill quantity (CIIs) remains; o Written on a medication order,form or ordered by peeling the top label from the label and placing it in the appropriate area on the order form provided by the pharmacy for that purpose, and requested from the pharmacy a minimum of 3 days in advance of need to assure an adequate supply is on hand. o If only one refill remains (CIII-Vs) or only a partial fill quantity remains (CIT), the pharmacy will simultaneously dispense the remaining fill, and, if necessary proactively seek out a new, complete prescription from the prescriber for future use. If a new prescription is not obtained by the pharmacy before the medication would be due again, the facility is notified. In this situation, the facility may be asked to contact the prescriber for a new prescription prior to the medication running out.

Based on interviews with the Administrator, Director of Nurses (DON), Medical Director, facility nurses and aides, Resident #206, a family member of Resident #206, and a Deputy with the local police department; review of facility documents, including policies and procedures on Abuse/Neglect/Exploitation, and training documents, admission documents and hospital records for Resident #206; and observation of the facility including the location of the resident's room and the elevators, and the potential route Resident #206 might have taken during his 5.1 mile walk away from the facility; it was determined the facility failed to identify incidents as reportable to the State Agency for two (#206, #68) of 8 residents sampled for abuse. Resident #206 was able to leave the facility by boarding an empty elevator that is code protected to ensure resident safety, ride the elevator to the first floor, get off of the elevator and walk out the front door, unobserved and unquestioned. He had been in the facility from 3:29 p.m. on 10/26/2022 as captured on video in the facility front hall until 3:52 p.m. on 10/26/2022 as captured on video leaving the facility; and not found until 10:30 a.m. on 10/27/2022 in a neighborhood park 5.1 miles away from the facility. Facility nursing staff did not notify the Director of Nurses or the Administrator until approximately 6:00 p.m. on 10/26/2022 that the resident's location was not known. The Administrator did not notify Law Enforcement until 6:47 p.m. on 10/26/2022 of the resident's unknown location. The State Agency was not notified of Resident #206's unknown whereabouts for 18 hours until two weeks after the event occurred. It was determined that staff had not implemented their training on the elevator protocol when Resident #206 was able to board an empty elevator, confirmed by no staff or visitor reporting they had seen or ridden down on the elevator with Resident #206, and walk out the front door with no staff questioning who he was or where he was going. This failure to report an incident to the State Agency when a newly admitted resident was able to leave the facility unsupervised created a situation that resulted in a worsened condition and the likelihood for serious injury and or death to Resident #206 and resulted in the determination of Immediate Jeopardy on 10/26/2022. The findings of Immediate Jeopardy were determined to be removed on 11/15/2022 and the severity and scope was reduced to a D. Findings included: A review of the facility's policy on their Abuse Prevention Program revealed the policy statement indicated the Facility has designated and implemented processes, which strive to reduce the risk of abuse, neglect, exploitation, mistreatment, and misappropriation of residents' property. These policies guide the identification, management, and reporting of suspected, or alleged, abuse, neglect, mistreatment, and exploitation. It is expected that these policies will assist the facility with reducing the risk of abuse, neglect, exploitation, and misappropriation of resident's property through education of staff and residents, as well as early identification of staff burn out, or resident behavior which may increase the likelihood of such events. The policy included a definition of neglect: Failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. The policy included the reasonable person concept, used to determine whether the resident has suffered psycho-social harm. The policy listed the procedure for staff to follow, according to the policy, in an effort to provide residents, visitors and staff with a safe and comfortable environment. The procedure included relevant points: *The designated shift supervisor is identified as responsible for immediate initiation of the reporting process. *The Administrator, Director of Nurses and/or designated individual are responsible for the investigation and reporting of suspected, or alleged, abuse, neglect, and exploitation and misappropriation. *The Administrator, Director of Nurses and/or designated individual are also ultimately responsible for the following: Implementation Ongoing monitoring Investigation Reporting Tracking and trending. Under the subheading of Reporting, the policy identifies the need for the facility to identify person(s) responsible for the reporting and investigating; that the facility will be in compliance with Federal regulations and State specific reporting requirements; and the facility will submit a report immediately for suspected abuse, neglect, or misappropriation. The immediate report must be filed not later than 24 hours after the allegation is made if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials, including State Survey Agencies and adult protective services where state law provides for jurisdiction in long-term care facilities. At the conclusion of the investigation and within 5 business days of the event, a final report will be submitted detailing the facility findings, to include whether the allegation is substantiated. The facility reports alleged violations and substantiated incidents to DPH (Department of Public Health), and all other agencies as required and takes necessary corrective actions depending on the results of the investigation. Resident responsible party is notified if the resident lacks capacity; if the resident has capacity the facility will request resident permission prior to notification of next of kin. Resident's physician is notified. 1. A review of the facility's Abuse/Neglect Log for October 2022 on 11/07/2022 revealed the incident related to Resident #206's ability to leave his resident floor unseen, get onto an empty elevator and ride it to the first floor and then walk out of the building unimpeded and unquestioned with his location unknown for 18 hours, was not listed. When the Administrator was asked why this incident would not have been listed on their Abuse/Neglect Log, (on 11/07/2022 in the interview that began at 11:00 a.m.) she reported that she had not viewed the resident's absence from the facility and unknown location as either abuse or neglect by the facility. She reported that once she was notified of the resident's absence, at approximately 6:00 p.m. on 10/26/2022, she reviewed admitting paperwork from the hospital for Resident #206. She reported the Admitting document, the 3008, indicated the resident's Mental/Cognitive Status at Transfer was identified as alert, oriented, follows instructions. She reported that the admitting documents indicated the resident was his own responsible party and she could not deny him his decision and ability to leave the building if he didn't want to remain. She reported that she had been told he told his nurse that he didn't want to be at the facility, and he thought he was going home when he was discharged from the hospital. An additional description of the resident's cognitive status and ability to make decisions is included in the 3008. The Administrator did not refer to it or report that she included that information in her assessment of whether the resident had the cognitive ability to decide that leaving the building without telling anyone was ok. The 3008 form includes a question about the decision-making capacity of the patient; the hospital marked that (Resident #206) required a surrogate. An Emergency contact with name and phone number was listed below the section asking to describe the resident's decision-making capacity. In an interview conducted with the Administrator on 11/14/2022 beginning at 9:30 a.m., she agreed to read staff statements about their interaction with Resident #206 on 10/26/2022. She confirmed two aides and one nurse were assigned to the unit where Resident #206 would be residing. One aide (CNA) saw the resident when he arrived on to the floor about 3:45 p.m. She reported she knew she wasn't assigned to him. She said later she saw him standing by the elevator, so she assisted him back to his room, and asked him if he needed anything. She reported that he asked for the TV to be turned on, which she did, and she ensured he had the TV remote and his call bell accessible. The resident's nurse, (RN HH) reported she saw the resident when he arrived on the floor initially and after that saw him at the elevator. She reported that she asked him to return to his room so she could get his vitals. She reported in her statement that he seemed angry but agreeable to return to his room. Her statement included no additional comments made by the resident. The lack of the resident's displeasure with being at the facility was not included in RN HH's statement and when that was questioned, the Administrator said that the nurse meant he wanted to leave when she wrote that he seemed angry. The DON added she had gone to the hospital to see Resident #206 on 10/28/2022. She reported the resident told her that he had been tricked, that he hadn't been told he was going to a rehab center as he thought he was going home to his ALF. In an interview with RN HH on 11/10/2022 beginning at 12:20 p.m., she reported that she had been on the phone with the doctor for the resident in the B bed as he wasn't doing well, and she saw the new resident in the A bed get up and walk out of the room. She said she spoke to him, letting him know she was his nurse and he said good. She said he said nothing else to her. She said she took his temperature but not the other vitals as the equipment wasn't handy to her. She said he was friendly, clean, but looked more like a visitor than a resident. She said she got busy with the other sick resident and also busy passing medications to her other residents, and she didn't know he had gotten onto the elevator and left the building. She said it wasn't until the aide told her that he wasn't in his room when they delivered the dinner trays that she knew he wasn't around. She said herself and one of the aides looked all around for him on the second floor without success. RN HH reported she didn't have the chance to review Resident #206's medications or his admitting paperwork. RN HH denied that the resident told her he didn't want to be there and said he only responded to her saying that she was his nurse. She reported that she felt not having a third nurse or a unit manager to observe and assist with the residents was the reason the resident was able to leave the floor unobserved. When asked about staff training on the elevator protocol, she reported that staff are not to walk away from an open elevator as a resident could get onto it. Admission documents received by the facility at the time Resident #206 arrived included a list of medications that were ordered for the resident. Medications that the resident should have received before bed included Olanzapine 5 mg for Schizophrenia; Gabapentin 400 mg for neuropathy; Budesonide inhalation for wheezing and shortness of breath; Divalproex sodium 500 mg for seizures; Formoterol 2 ml inhalation for shortness of breath; Lorazepam 1 mg for anxiety; Melatonin 3 mg for insomnia; Metoprolol 25 mg for hypertension and Tizandinine 4 mg for muscle spasms. A review of the job description for the Unit Manager, undated, revealed in the Summary of the Position, the Unit Manager, (UM-RN) is responsible for overseeing direct nursing care to assigned residents/patients. The UM-RN assumes responsibility and accountability for the nursing care and services provided on the assigned unit. The UM-RN is responsible for and adheres to the standards of care for assigned residents/patients, assists with data collection, monitoring and implementation of physician orders based on individual resident/patient needs, manages the environment to maintain resident/patient safety, and supervises the resident/patient care activity performance by licensed nurses and certified nursing assistants. Under Essential Duties and Responsibilities was a bullet point that read: Oversees the assessments of the resident/patient admission process. In an interview with facility staff on 11/14/2022 beginning at 9:30 a.m., the lack of a Unit Manager for the second floor was raised. The Administrator reported that a Unit Manager for the second floor had been hired. The DON reported that unit managers remain until 4 p.m. or 5 p.m. during the week and after that the charge nurse is available to assist the nurse on the floors. She reported that the Unit Managers work the day shift and assist with what needs to be done, including remaining at the nursing station to answer the phone and watch the elevator. She reported without a Unit Manager assigned to the floor, the other Unit Managers from the third and fourth floor were to assist and the DON and ADON were available also. In an interview conducted with the resident on 11/07/2022 beginning at 9:10 a.m., he confirmed he had walked out of the Rehab Center and ended up in a park. He confirmed he had been out all night and had had nothing to eat. With a laugh he said he was glad it hadn't rained that night. He reported he had been dropped off at the facility and could not remember how he got up to his room. He reported he had been lying in his bed, but then got up, walked into the hall and no one was around. He said the elevator came up, the door opened, and a staff member got out and walked away and he got onto the elevator. He reported the elevator took him to the first floor and he walked out the front door and no one said anything to him. He said he was trying to get back to his ALF, but he turned the wrong way and walked until he ended up in the park. He confirmed the police confronted him in the park due to what he was wearing, and he told the police that he was short of breath. He was taken back to the hospital that he had left the day before and remained until 11/01/2022 when he was discharged back to his ALF. Observation of the facility revealed it was a four story L shaped building on the corner of two main streets. The building's parking lot was adjacent to an outpatient building with roads leading past the building to the two main streets. Across the street from the facility was a major hospital with an ER and multiple entrances into the ER and parking lots. The entrance to the facility was approximately 88 feet from the Receptionist Desk, which included an entry hall of 26 feet, which ended in a T intersection. The Elevator was 42 feet from the intersection of the two halls and the reception desk another 20 feet from the elevator. The resident's room on the second floor was two doors down from elevator, with a nursing station in front of the elevators. The staffing sheet for 10/26/2022 did not list a unit manager on duty on the second floor, who would have worked from the nursing station. Two nurses and four aides were assigned to the 3-11 shift on the second floor. The potential route that the resident took was identified as walking west out of the facility parking lot, and turning north on a four-lane road with a speed limit of 45 mph. The distance between the facility and the park where the Deputy found the resident was 5.1 miles along roads that ranged from two to four lanes, some roads straight and some curvy, with sidewalks that changed from one side of the road to the other and sometimes ended in dirt paths. Walking north would have taken the resident past intersections that widened into multiple lanes with turn lanes. Speed limits ranged from 25 to 45 mph. The resident was seen leaving the facility at 3:52 p.m. on video. Shift change occurs at 3:00 p.m. and a smoking break for the residents is planned for 4:00 p.m. The resident reported seeing no staff in the area around the elevator on the second floor, except for the staff member who exited the elevator and walked away from the elevator leaving the door open, and available for Resident #206 to enter, ride to the first floor, and walk out of the building, unnoticed. The resident reported no one on the first floor stopped him or asked where he was going. Resident #206 according to hospital records, was admitted on [DATE] with a History and Physical (H&P) documented at 3:54 p.m. The H&P documented the patient as a [AGE] year-old male with past medical history significant for schizoaffective disorder, hypertension, seizure disorder and COPD (chronic obstructive pulmonary disease), presented to the emergency department via EMS from his ALF (Assisted Living Facility) with complaints of worsening weakness. Has extensive psychiatric history and on multiple medications for schizoaffective disorder. Currently patient lethargic and unable to give much history. Audible wheezing throughout his lung fields with poor air movement. The Hospital Course as documented in the Discharge Summary dated 10/26/2022 listed diagnoses as COPD with exacerbation with respiratory insufficiency, seizure disorder, schizoaffective disorder, bipolar type, hypertension, and metabolic versus toxic encephalopathy. Treatment during the hospital stay included a psychiatry consult that adjusted medications, resulting in the patient becoming combative and uncooperative on the day of discharge. Both a concern with a history of noncompliance and refusing medications at the ALF as well as a concern with being overmedicated due to lethargy were documented. Physical Therapy had been consulted. The patient was described as lacking insight and good judgement. Initially the discharge plan was to return to the ALF, but the ALF had reportedly felt the patient's needs could not be met at the ALF and they were recommending the resident admit to a skilled nursing facility. Resident #206 was admitted to the Rehab Center on 10/26/2022 at 3:29 p.m., as captured on video taken in the entrance hall of the facility. The resident was observed to walk into the building following the Transporter who led the resident to the Reception Desk. An interview was conducted with the Admissions Coordinator on 11/06/2022 beginning at 12:05 p.m. She reported remembering when Resident #206 was admitted . She said she happened to be near the reception desk and saw a Transporter walking in with a resident walking behind him, with no assistive device. She said Therapy was contacted for a wheelchair and once they brought a wheelchair to Reception, Resident #206 sat down in it, and she took him up to his room. She confirmed he had admission paperwork with him. She reported once the resident was in his room, she assisted him into his bed and began to familiarize him with the room and his call bell. She said he seemed fine, and he didn't say much, including anything about having been admitted to the facility. She said that she let the nurse know her new admission had arrived and then she left the floor. She reported that she went home a few hours later but was called back in to assist in searching for Resident #206 as he didn't seem to be anywhere in the building. She confirmed assisting in the search, but they were not able to find him that night. She said she went home and when she returned the next morning, she learned his location was still unknown. The facility called their Code Silver (Missing Resident) Drill on 10/26/2022 at 6:06 to search inside the building for Resident #206. The Overview for the Missing Resident/Patient Action Plan read: To assist in guiding the facility with suggested activities in response to a missing resident/patient. The form is not intended as an all-inclusive list of actions, rather a prompt of some key areas to review or perform. The completed form was reviewed and noted that according to decisions the facility made on the Elopement Decision Tree, reporting to the state agency was not applicable. An interview with the Administrator on 11/07/2022 which began at 11:00 a.m. confirmed that she had not reported the incident related to Resident #206 whose location was unknown for 18.5 hours to the State Agency. She confirmed she had not identified it as an Elopement as the resident was alert and oriented and able to make the decision that he would leave the facility. She reported that she was still investigating the incident and would submit her State report on 11/09/2022, as that would be day 15. A review of the Elopement Decision Tree revealed the first question read: Did a resident /patient leave the premises or a safe area without authorization and/or necessary supervision and was resident at risk for harm or injury? The facility answered NO to this question which guided the facility to stop as this was not considered an elopement. When the Administrator was asked why the question was answered No - as the resident had left the premises, considered a safe area, without authorization or supervision and he was at risk for harm or injury, she reported, on 11/07/2022 in the interview that began at 11:00 a.m., that because the resident's admission documents from the hospital indicated he was alert and oriented and his own person, he had the authority to leave. The Administrator provided the guidance used when investigating an incident to determine whether the resident experienced harm as a result of the incident. The first bullet point asked whether the resident experienced physical, emotional, or mental injury. The facility's documented response read, no injury reported by law enforcement (LE) or hospital. When asked about this statement, the Administrator re-iterated that neither LE nor the hospital found any injury. There was no evidence of a mental health assessment in the hospital notes, so the answer No was not founded on any evidence of an assessment by social services or psychological staff. There was a question about the likelihood that the resident could have experienced physical, emotional, or mental injury to which the answer had been documented as No. As the resident had been away from the facility for 18.5 hours, overnight, outside and in a park, there was likelihood that the resident could have experienced physical, emotional, or mental injury. A question asked if the resident was at risk for being hit by a motor vehicle with the answer No, used sidewalks while exiting the premises. The location at which the resident was found was 5.1 miles away. Driving a potential, direct route from the facility to the location in the park where he was found revealed some areas of the route which ranged from narrow two-lane streets to wide busy four lane streets, some without sidewalks, intersections with traffic lights, and turn lanes. Observation of the photo of the resident arriving to the facility could not identify what the resident had on his feet. His pants were long and covered some of his feet, and it was difficult to identify whether the resident had soft moccasin like shoes on or only socks. The guidance document asked about appropriate clothing and the documentation read: resident was wearing long sleeved flannel shirt, long pants, and nonskid socks. There was nothing documented about shoes. The Administrator reported, in an interview conducted on 11/07/2022 beginning at 11:00 a.m., she had spoken with the resident on 10/27/2022 when he was at the hospital, and he told her that he was able to get onto the elevator when someone else got off. When a request was made for the policy or protocol for the secured, coded elevator, the Administrator provided an in-service that had been conducted on 10/27/2022 instead. In an interview that was conducted with the Administrator on 11/07/2022 beginning at 11:00 a.m., she confirmed in her review of the admitting documents that the resident was alert and oriented and his own person. She reported that his admitting nurse had reported that the resident told her that he didn't know he was being admitted to a rehab facility and he had wanted to go back to his ALF. She reported that he was able to leave the building based on his cognitive status; she couldn't refuse to let him leave as that would violate his rights. The Administrator reported a timeline that had been developed from the staff interviews and video of the resident arriving and leaving. She said that the resident was observed walking into the building at 3:29 p.m. and walking out of the building at 3:52 p.m. She confirmed that the resident's aide initially reported that the resident was not in his room when she went in to deliver his dinner tray. She reported she learned the resident's location was unknown at 6:00 p.m. at which time a Code Silver (Elopement protocol) was called, and staff were asked to conduct an internal search. She reported the internal search was conducted from 6:06 p.m. until 6:13 p.m. She said after learning that the resident was not located in the building, she sent staff out in pairs to drive around the vicinity to look for him. The Administrator confirmed that the initial search of the building took only 7 minutes due to many of the staff having been in the building and joining in the search. In a second interview with the Administrator on 11/14/2022 beginning at 9:30 a.m., when asked if a timeline had been developed from the staff interviews during the time the resident was in the building, the Administrator reported that none of the interviews indicated anyone took the elevator down with the resident, including staff and visitors, and no one admitted to having walked away from the elevator, leaving it open for the resident to get on and leave the floor. The question about how they accessed the elevator was not asked, so it is not known whether the elevator was standing open after someone else walked out of the elevator, or if they knew the code, or if someone had entered the code for them. There was no detailed timeline of who was on the second floor at what time, whether they were on the elevator, got off the elevator or who entered the elevator code to let the visitors off of the floor. The facility questioned visitors to the facility from 10/26/2022 about whether anyone rode in the elevator with them. The audit tool used to document visitor responses to their questioning about the late afternoon of 10/26/2022 only asked if someone rode down on the elevator with them. It didn't ask who input the code to allow them off the elevator, or if the elevator came up to the floor, someone got off which allowed them to get on. An interview was conducted with the Medical Director on 11/09/2022 beginning at 8:30 a.m. He reported that the Administrator had notified him of a resident who had left the facility unescorted, but he could not identify the day that he had been made aware. He reported he agreed with the Administrator's decision that the resident was alert and oriented therefore she could not make the resident stay. When asked if the resident's surrogate should have been involved in a decision to leave the facility, he reported that would be best, but he had been told the resident left right away. He said the better way to leave would be for the resident to let his nurse know his plan to leave, sign a document and the nurse should write a note. On 11/08/22 at 10:24 a.m., an interview was conducted with the Resident #206's family member. He confirmed he heard from the police on 10/26/22 at 10:30 p.m. and again on 10/27/22 at 7:00 am. about his missing brother. He reported that he did not hear from the facility that his family member was able to get out of the facility. The family member had been made aware of where the resident was found and reported that the resident can hardly walk and didn't know how he made it so far. He said even with his walker the resident was unstable and he didn't know if he had his walker with him. He had heard the resident went to the rehab facility and was able to leave from there, which seemed pretty easy. He confirmed he was told they didn't find him until the next morning and then they took him to the hospital. When asked about the resident's cognitive status, the family member reported the resident can make decisions, but his health is bad, so he needs help with medications. He confirmed the resident takes medications for schizophrenia. He reported he was hard to hear and understand as the resident talks so low. He reported the resident can make everyday decisions, but long-term or involved decisions, like understanding if he doesn't go to rehab, he may not be able to stay at the ALF, are hard for him. The family member reported that he told Resident # 206 to go to rehab or the ALF wouldn't take him back. He reported that the hospital never called him to let him know that they were sending the resident to a rehab facility. He confirmed he was the resident's Health Care Surrogate and Power of Attorney. An interview was conducted on 11/08/22 at 10:55 AM with the Deputy who found Resident # 206 mid-morning on 10/27/2022. The Deputy reported that the call identified a missing adult/endangered, white male, about 60-years old, walking around with his pants down, exposing his buttocks. He said the resident was wearing a blue t-shirt and blue pants, that could be identified as scrubs. The resident was found near a park in a neighborhood, and he looked disoriented. The resident was able to tell him his name and date of birth, and then told the deputy that he was short of breath. The deputy reported that they called the EMS who took him to the hospital that he had been discharged from. Facility immediate actions to remove the Immediate Jeopardy included: The facility reported that they were made aware at the exit conference held on 11/09/2022 for the Recertification and Complaint Surveys that there was an allegation of Neglect, related to Resident #206. The facility submitted a Federal Immediate Report on 11/09/2022 and confirmed that the Administrator was responsible for submitting reports to the State Agency. The Administrator reported she was finishing the 5 day report. The Administrator reported the incident to the State Agency on 11/09/2022. The agency didn't accept the report with the comment, based on the information provided, a report for investigation is not being accepted because the concerns do not rise to the level of reasonable cause to suspect harm. The Abuse Registry was notified on 11/09/2022 of the allegation of Neglect. The Administrator and Director of Nursing and all facility staff were educated on State and Federal reporting requirements. The Administrator and Director of Nursing reviewed their job descriptions and re-signed them as indicating they had been re-educated on their responsibilities. IDT will review new admissions historical information, preadmission screen, and the 3008 for inconsistencies in cognition and will place the resident 1:1 upon admission to evaluate elopement status and safeguards are put in place. Facility staff were educated on reporting those residents who exhibit exit seeking behaviors to ensure the appropriate immediate interventions be initiated. Staff were educated on reporting any resident who voices a desire to leave or go home. Staff are asked to remain with the resident to ensure their safety until an evaluation of the resident's desire is conducted by the nurse. Aides are to report to their nurses who are to report to their Nursing Supervisor, Director of Nurses or Administrator. All staff are to report to their direct supervisors who are to report to the Administrator or Director of Nurses. Facility staff interviewed on 11/15/2022 related to reporting incidents alleging neglect were found to be knowledgeable about their responsibility. The facility produced documentation to show that 88 % of the staff had received training, and that the facility would inservice staff not trained as they reported for duty. Interviews were conducted with 14 staff, 5 licensed nurses, 5 CNAs and 4 other staff. The staff members were able to state that they had been trained and were knowledgeable about the new policies. 2. On 11/7/22 at 10:22 a.m., Resident #68 stated that a Certified Nursing Assistant had yelled at her. The resident said she requested a salad for dinner and received a salad for lunch then again for dinner. The resident stated she informed the Certified Nursing Assistant, CNA, (resident did not [TRUNCATED]

Based on a review of facility's investigation of an event that occurred on 10/26/2022 when Resident #206 was able to enter a coded elevator that stood open, ride the elevator to the first floor, exit the elevator and walk out the front door of the building unescorted and not questioned by staff, a review of hospital records including admission records to the facility; interview with Resident #206, a family member of Resident #206, the Medical Director, the Administrator, Director of Nurses (DON), and facility staff; and observation of the facility, the resident's room and location of the elevators and the potential route that Resident #206 walked, it was determined that the facility failed to fully investigate the reason why one (Resident #206) of 8 residents sampled for abuse was able to leave the facility through an elevator described as secured by the use of a code to enter, with his location unknown for 18.5 hours. Resident #206, a vulnerable male known to use a walker to ambulate safely, was found 18.5 hours after he was caught on camera exiting the facility, 5.1 miles from the facility in a neighborhood park. This failure to complete a thorough investigation in a timely manner to determine the cause of the event and prevent a recurrence resulted in findings of Immediate Jeopardy due to the likelihood that another resident could leave the facility by the same means. The Immediate Jeopardy began on 10/26/2022 and was determined to be removed on 11/15/2022 and the severity and scope was reduced to a D. Findings included: A review was conducted of the facility's policy on their Abuse Prevention Program. The Policy statement read: The facility has designated and implemented processes which strive to reduce the risk of abuse, neglect, exploitation, mistreatment, and misappropriation of resident's property. These policies guide the identification, management, and reporting of suspected, or alleged, abuse, neglect, mistreatment, and exploitation. It is expected that these policies will assist the facility with reducing the risk of abuse, neglect, exploitation, and misappropriation of resident's property through education of staff and residents, as well as early identification of staff burn out, or resident behavior which may increase the likelihood of such events. The policy included a section on Definitions which defined Neglect as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. The policy included a section on the Procedure in an effort to provide residents, visitors and staff with a safe and comfortable environment. Point #3 read: The Administrator, DON (Director of Nurses) and/or designated individual are responsible for the investigation and reporting of suspected, or alleged, abuse, neglect, and exploitation and misappropriation. The Administrator, DON, and/or designated individual are also ultimately responsible for the following: Implementation Ongoing monitoring Investigation Reporting Tracking and trending. The section under Investigation provided guidance: An Event Report is initiated; NHA or designate is notified and, in collaboration with Risk Management Specialist will initiate and conclude a complete and thorough investigation within the specified timeframe. The Investigation may include, but may not be limited to: Resident statements/interviews Employee statements/interviews Visitor statements/interviews Observation of resident (s), staff, environment Document review, i.e., chart reviews, policy review, education programs, appropriate resource review (such as medical literature); and Re-enactment of event. A review was conducted of the Job Description for the Facility Risk Manager. In the interview with the Administrator which was conducted on 11/07/2022 beginning at 11:00 a.m., the Administrator confirmed that she was the Risk Manager for the facility. The Summary of the Position contained in the Job Description for the Risk Manager read: The Risk Manager is responsible for planning, organizing, and coordinating all aspects of the Clinical Risk Management program within the facility. The Risk Manager collaborates with the NHA (nursing Home Administrator), Facility Staff, Physicians, Residents and Families to make available the provision of quality care by the identification of potential and actual problems with subsequent formulation of solutions to alleviate these problems through the facilities internal risk management/quality assurance program. Under Essential Duties and Responsibilities, a bullet point indicated: Manages, analyzes, and trends resident, patients, and employee events. Under Abilities, a bullet point indicated: The ability to tell when something is wrong or is likely to go wrong. It does not involve solving the problem, only recognizing there is a problem. A review of the Facility Assessment, dated 11/23/2021, revealed a section describing categories of residents defined by physical disabilities which included residents at risk of elopement. At the time of the assessment there were 15 residents identified as being at risk for elopement. At the time of the incident which occurred on 10/26/2022 when Resident #206 was able to walk onto an empty elevator and then out the front door unimpeded, there were 18 residents assessed as being at risk for elopement or exit seeking behavior. A review of the category used to define what equipment the facility had available or planned to obtain equipment that would be used to assist these residents identified as elopement risks was conducted. To maintain a safe environment for residents at risk of elopement, the facility had a door security system, with delay egress; acute awareness of those residents at risk and who required supervision. Mirrors and monitors were added at the front desk for maintaining a secured environment. A change in the assessment and risk identification was noted. There was no reference to the use of a coded elevator, with only staff having knowledge of the code, to maintain the safety of the residents at risk for elopement. A review of the facility's Abuse/Neglect Log for October 2022 on 11/07/2022 revealed the incident related to Resident #206's ability to leave his resident floor unseen, get onto an open and empty, potentially secured elevator and ride it to the first floor and then walk out of the building unimpeded and unquestioned with his location unknown for 18.5 hours, was not listed. When the Administrator was asked why this incident would not have been listed on their Abuse/Neglect Log, (on 11/07/2022 in the interview that began at 11:00 a.m.) she reported that she had not viewed the resident's absence from the facility and unknown location as either abuse or neglect by the facility. She reported that once she was notified of the resident's absence, at approximately 6:00 p.m. on 10/26/2022, she reviewed admitting paperwork from the hospital for Resident #206. She reported the Admitting document, the 3008, indicated the resident's Mental/Cognitive Status at Transfer was identified as alert, oriented, follows instructions. She reported that the admitting documents indicated the resident was his own responsible party and she could not deny him his decision and ability to leave the building if he didn't want to remain. She reported that she had been told he told his nurse that he didn't want to be at the facility, and he thought he was going home when he was discharged from the hospital. A review was conducted of the admitting documents from the hospital which included the 3008. On page 1 of 2 pages of the 3008, Section C. Decision making capacity (patient) was marked as requires a surrogate. Section D listed an Emergency Contact and phone number. Section E Medical Condition on the 3008 listed Weakness as the diagnosis. Section G Patient Risk Alerts listed falls. Page 2 of the 3008 Section S Physical Function identified the resident as ambulating independently, self-transfers, no devices in use (such as a wheelchair) and full weight bearing ability on left and right sides. Section U of the 3008 Mental/Cognitive Status at Transfer identified the resident as Alert, oriented, follows instructions. Another document sent in the admission packet, the Pre-Admission Screening Tool, dated 10/25/2022, was reviewed and noted to describe the resident's Cognition/Behavior. The form documented the resident's current cognition level as A&Ox1-2 (alert and oriented x one to two). (Alert and oriented x 3 indicates an individual that is oriented on three levels: person, place, and time. The nurse documenting on the Pre-Admission Screening Tool did not explain which orientation the resident was missing.) The form answered No to confused and mobile, with a note on the form indicating a confused and mobile patient would be considered an elopement risk. The form described the patient as so sweet despite psych (psychiatric) history. His mobility status was described as ambulatory, with minimum assistance, with no weight bearing precautions but having had recent falls. The pre-admission screening did not list the resident as requiring oxygen. According to the interview with the Administrator on 11/07/2022 beginning at 11:00 a.m. her preliminary investigation once she was notified that a newly admitted resident had not remained in the facility was based on one section of the 3008 which described the resident as alert, oriented, follows instructions. Even though the 3008 included additional information on the resident's ability to make decisions with the emergency contact name and phone number listed below that information. The hospital's pre-screening information from the hospital included the admission diagnosis as weakness and falls, a description of the resident as alert and oriented x 2, minimal assistance needed for ambulation, and having had recent falls. In an interview conducted with the resident on 11/07/2022 beginning at 9:10 a.m., he confirmed he had walked out of the facility and ended up in a park. He confirmed he had been out all night and had had nothing to eat. With a laugh he said he was glad it hadn't rained that night. He reported he had been dropped off at the facility and could not remember how he got up to his room. He reported he had been lying in his bed, but then got up, walked into the hall and no one was around. He said the elevator came up, the door opened, and a staff member got out and walked away and he got onto the elevator. He reported the elevator took him to the first floor and he walked out the front door and no one said anything to him. He said he was trying to get back to his ALF (Assisted Living Facility), but he turned the wrong way and walked until he ended up in the park. He confirmed the police confronted him in the park due to what he was wearing, and he told the police that he was short of breath. He was taken back to the hospital that he had left the day before and remained until 11/01/2022 when he was discharged back to his ALF. Resident #206 was admitted to the facility on [DATE] at 3:29 p.m., as captured on video taken of the entrance of the facility. The resident was observed to walk into the building following the Transporter who led the resident to the Receptionist Desk. In an interview was conducted with the Admissions Coordinator on 11/06/2022 beginning at 12:05 p.m. she reported remembering when Resident #206 was admitted . She said she happened to be near the Receptionist's desk and saw a Transporter walking in with a resident walking behind him, with no assistive device. She said therapy was contacted for a wheelchair and once they brought a wheelchair to reception, Resident #206 sat down in it, and she took him up to his room. She confirmed he had admission paperwork with him. She reported once the resident was in his room, she assisted him into his bed and began to familiarize him with the room and his call bell. She said he seemed fine, and he didn't say much, including anything about having been admitted to the facility. She said that she let the nurse know her new admission had arrived and then she left the floor. She reported that she went home a few hours later but was called back in to assist in searching for Resident #206 as he didn't seem to be anywhere in the building. She confirmed assisting in the search, but they were not able to find him that night. She said she went home and when she returned the next morning, she learned his location was still unknown. In an interview conducted with the Administrator on 11/14/2022 beginning at 9:30 a.m., she agreed to read staff statements about their interaction with Resident #206 on 10/26/2022. She confirmed two aides, and one nurse were assigned to the unit where Resident #206 would be residing. One aide (CNA QQ) saw the resident when he arrived on to the floor about 3:45 p.m. She reported she knew she wasn't assigned to him. She said later she saw him standing by the elevator, so she assisted him back to his room, and asked him if he needed anything. She reported that he asked for the TV to be turned on, which she did, and she ensured he had the TV remote and his call bell accessible. The resident's nurse, (RN HH) reported she saw the resident when he arrived on the floor initially and after that saw him at the elevator. She reported that she asked him to return to his room so she could get his vitals. She reported in her statement that he seemed angry but agreeable to return to his room. Her statement included no additional comments made by the resident. The resident's displeasure with being at the facility was not included in RN HH's statement and when that was questioned, the Administrator said that the nurse meant he wanted to leave when she wrote that he seemed angry. The DON added she went to the hospital to see Resident #206 on 10/28/2022. She said the resident told her he had been tricked, that he hadn't been told he was going to a rehab center as he thought he was going home to his ALF. In an interview with RN HH on 11/10/2022 beginning at 12:20 p.m., she reported that she had been on the phone with the doctor for the resident in the B bed as he wasn't doing well, and she saw the new resident in the A bed get up and walk out of the room. She said she spoke to him, letting him know she was his nurse and he said good. She said he said nothing else to her. She said she took his temperature but not the other vitals as the equipment wasn't handy to her. She said he was friendly, clean, but looked more like a visitor than a resident. She said she got busy with the other sick resident and also busy passing medications to her other residents, and she didn't know he had gotten onto the elevator and left the building. She said it wasn't until the aide told her that he wasn't in his room when they delivered the dinner trays that she knew he wasn't around. She said herself and one of the aides looked all around for him on the second floor without success. RN HH reported she didn't have the chance to review Resident #206's medications or his admitting paperwork. RN HH denied that the resident told her he didn't want to be there and said he only responded to her saying that she was his nurse. She reported that she felt not having a third nurse or a unit manager to observe and assist with the residents was the reason the resident was able to leave the floor unobserved. When asked about staff training on the elevator protocol, she reported that staff are not to walk away from an open elevator as a resident could get onto it. Admission documents received by the facility at the time Resident #206 arrived included a list of medications that were ordered for the resident. Medications that the resident should have received before bed included Olanzapine 5 mg for Schizophrenia; Gabapentin 400 mg for neuropathy; Budesonide inhalation for wheezing and shortness of breath; Divalproex sodium 500 mg for seizures; Formoterol 2 ml inhalation for shortness of breath; Lorazepam 1 mg for anxiety; Melatonin 3 mg for insomnia; Metoprolol 25 mg for hypertension and Tizandinine 4 mg for muscle spasms. At the time of the resident's ability to board the elevator unobserved and exit the elevator and out through the front door, visitors were not required to wear name badges identifying them as visitors. During the Recertification Survey, done in conjunction with the survey team's investigation of the incident with Resident #206 and his unknown location for 18 hours after being admitted to the facility, staff were observed to be working without identification badges. The Administrator reported, in an interview conducted on 11/07/2022 beginning at 11:00 a.m., she had spoken with the resident on 10/27/2022 when he was at the hospital, and he told her that he was able to get onto the elevator when someone else got off. When a request was made for the policy or protocol for the secured, coded elevator, the Administrator provided an in-service that had been conducted on 10/27/2022 instead. The in-service document dated 10/27/2022 listed objectives for the training. She confirmed there wasn't a specific or formal policy for maintaining the safety of the elevator that included the situation that allowed Resident #206 to get on an unsecured elevator and leave the building unescorted and without staff knowledge. The objectives of the in-service were: elevator code should not be shared with residents or families; any staff member who gives code to unauthorized persons will be subject to disciplinary action or possible termination; alarms should be checked and verified that residents are not exit seeking. Even though the resident told the Administrator that he was able to get onto the elevator when someone else got off, the information that staff need to watch the elevator door close before walking away to ensure a resident doesn't get onto it was not included in the in-service. On 11/14/2022 at approximately 9:30 a.m., the Administrator reported that a new Elevator Management Process had been developed on 11/10/2022 and staff had been in-serviced on the objectives listed on the 10/27/2022 in-service as well as on the new process developed on 11/10/2022. The Elevator Management Process, dated 11/10/2022, read: Facility has educated staff on resident, vendor, and staff safety with regards to elevator management. Facility staff should check before and after entering/exiting facility elevators to ensure resident/s or unauthorized person/s do not attempt to tailgate or entry/exit to elevator. Unauthorized person refers to anyone without an employee name badge or visitors sticker. Person/s without an employee badge or visitors sticker will be referred to front desk to check in, if on a unit, the person/s will need to be referred to a Nurse and/or supervisor. In an interview with the Administrator which occurred on 11/14/2022 beginning at 9:30 a.m., the timeline that had been developed to investigate the resident's ability to leave the facility through a secured elevator and out the front door without being questioned, was reviewed. The Administrator reported that the resident was observed walking into the building on 10/26/2022 at 3:29 p.m. and walking out of the building at 3:52 p.m. She confirmed that the resident's aide told her nurse that the resident was not in his room when she went in to deliver his dinner tray. She reported she was notified at 6:00 p.m. that the resident's location was unknown. She reported she reviewed admission documents for the resident's cognition and determined the resident had not eloped as he was alert and oriented. However, a Code Silver (Elopement protocol) was called, and staff were asked to conduct an internal search for the resident. She reported the internal search was conducted from 6:06 p.m. until 6:13 p.m. She said after learning that the resident was not located in the building, she sent staff out in pairs to drive around the vicinity of the facility to look for him. The Administrator confirmed that the initial search of the building took only 7 minutes due to many of the staff having been in the building and joining in the search. A review of the Overview for the Missing Resident/Patient Action Plan read: To assist in guiding the facility with suggested activities in response to a missing resident/patient. The form is not intended as an all-inclusive list of actions, rather a prompt of some key areas to review or perform. The completed form was reviewed and noted that according to decisions the facility made on the Elopement Decision Tree, reporting to the state agency was not applicable. An interview with the Administrator on 11/07/2022 which began at 11:00 a.m. confirmed that she had not reported the incident related to Resident #206 whose location was unknown for 18.5 hours to the State Agency. She confirmed she had not identified it as an Elopement as the resident was alert and oriented and able to make the decision that he would leave the facility. She reported that she was still investigating the incident and would submit her State report on 11/09/2022, as that would be day 15. A review of the Elopement Decision Tree revealed the first question: Did a resident /patient leave the premises or a safe area without authorization and/or necessary supervision and was resident at risk for harm or injury? The facility answered NO to this question which guided the facility to stop as this was not considered an elopement. When the Administrator was asked why the question was answered No, as the resident had left the premises, considered a safe area, without authorization or supervision and he was at risk for harm or injury, she reported, on 11/07/2022 in the interview that began at 11:00 a.m., that because the resident's admission documents from the hospital indicated he was alert and oriented and his own person, he had the authority to leave. The Administrator provided the guidance used when investigating an incident to determine whether the resident experienced harm as a result of the incident. The first bullet point asked whether the resident experienced physical, emotional, or mental injury. The facility's documented response read, no injury reported by law enforcement (LE) or hospital. When asked about this statement, the Administrator re-iterated that neither LE nor the hospital found any injury. There was no evidence of a mental health assessment in the hospital notes, so the answer No was not founded on any evidence of an assessment by social services or psychological staff. There was a question about the likelihood that the resident could have experienced physical, emotional, or mental injury to which the answer had been documented as No. As the resident had been away from the facility for 18.5 hours, overnight, outside and in a park, there was likelihood that the resident could have experienced physical, emotional, or mental injury. A question asked if the resident was at risk for being hit by a motor vehicle with the answer No, used sidewalks while exiting the premises. The location at which the resident was found was 5.1 miles away. Driving a potential, direct route from the facility to the location in the park where he was found revealed some areas of the route which ranged from narrow two-lane streets to wide busy four lane streets, some without sidewalks, intersections with traffic lights, and turn lanes. Observation of the photo of the resident arriving to the facility could not identify what the resident had on his feet. His pants were long and covered some of his feet, and it was difficult to identify whether the resident had soft moccasin like shoes on or only socks. The guidance document asked about appropriate clothing and the documentation read: resident was wearing long sleeved flannel shirt, long pants, and nonskid socks. There was nothing documented about shoes. In the interview with the Administrator on 11/14/2022 beginning at 9:30 a.m., when asked if a timeline had been developed from the staff interviews during the time the resident was in the building, the Administrator reported that none of the interviews indicated anyone had taken the elevator down with the resident, including staff and visitors, and no one admitted to having walked away from the elevator, leaving it open for the resident to get on and leave the floor. The Administrator reported that the Director of Nurses had phoned those visitors who had signed the visitor log on 10/26/2022 during the time period that Resident #206 had arrived at and then left the facility. The DON confirmed she was not able to contact every visitor, but no visitor said they rode down on the elevator with someone else. The question about how they accessed the elevator was not asked, so it is not known whether the elevator was standing open after someone else walked out of the elevator, or if the visitors knew the code, or if someone had entered the code for them. There was no detailed timeline of who was on the second floor at what time, whether they were on the elevator, got off the elevator or who entered the elevator code to let the visitors off the floor. There was no set of questions used to fully investigate staff statements or to ensure that the statements were complete and could identify who was the last person to leave the elevator, allowing it to remain open and providing an empty, unsecured elevator for Resident #206 to enter, ride to the first floor and walk out of the building unimpeded. Resident #206 had been living in a local ALF prior to a hospitalization for increasing weakness. According to hospital records, the resident was admitted on [DATE] with a History and Physical (H&P) documented at 3:54 p.m. The H&P documented the patient as a [AGE] year-old male with past medical history significant for schizoaffective disorder, hypertension, seizure disorder and COPD (chronic obstructive pulmonary disease), presented to the emergency department via EMS from his ALF (Assisted Living Facility) with complaints of worsening weakness. Has extensive psychiatric history and on multiple medications for schizoaffective disorder. Currently patient lethargic and unable to give much history. Audible wheezing throughout his lung fields with poor air movement. The Hospital Course as documented in the Discharge Summary dated 10/26/2022 listed diagnoses as COPD with exacerbation with respiratory insufficiency, seizure disorder, schizoaffective disorder, bipolar type, hypertension, and metabolic versus toxic encephalopathy. Treatment during the hospital stay included a psychiatry consult that adjusted medications, resulting in the patient becoming combative and uncooperative on the day of discharge. Both a concern with a history of noncompliance and refusing medications at the ALF as well as a concern with being overmedicated due to lethargy were documented. Physical Therapy had been consulted. The patient was described as lacking insight and good judgement. Initially the discharge plan was to return to the ALF, but the ALF had reportedly felt the patient's needs could not be met at the ALF and they were recommending the resident admit to a skilled nursing facility. An interview was conducted with the Medical Director on 11/09/2022 beginning at 8:30 a.m. He reported that the Administrator had notified him of a resident who had left the facility unescorted, but he could not identify the day that he had been made aware. He reported he agreed with the Administrator's decision that the resident was alert and oriented therefore she could not make the resident stay. When asked if the resident's surrogate should have been involved in a decision to leave the facility, he reported that would be best, but he had been told the resident left right away. He said the better way to leave would be for the resident to let his nurse know his plan to leave, sign a document and the nurse should write a note. On 11/08/22 at 10:24 a.m., an interview was conducted with the Resident #206's family member. He confirmed he heard from the police on 10/26/22 at 10:30 p.m. and again on 10/27/22 at 7:00 am. about his missing brother. He reported that he did not hear from the facility that his family member was able to get out of the facility. The family member had been made aware of where the resident was found and reported that the resident can hardly walk and didn't know how he made it so far. He said even with his walker the resident was unstable and he didn't know if he had his walker with him. He had heard the resident went to the rehab facility and was able to leave from there, which seemed pretty easy. He confirmed he was told they didn't find him until the next morning and then they took him to the hospital. When asked about the resident's cognitive status, the family member reported the resident can make decisions, but his health is bad, so he needs help with medications. He confirmed the resident takes medications for schizophrenia. He reported he was hard to hear and understand as the resident talks so low. He reported the resident can make everyday decisions, but long-term or involved decisions, like understanding if he doesn't go to rehab, he may not be able to stay at the ALF, are hard for him. The family member reported that he told Resident # 206 to go to rehab or the ALF wouldn't take him back. He reported that the hospital never called him to let him know that they were sending the resident to a rehab facility. He confirmed he was the resident's Health Care Surrogate and Power of Attorney. An interview was conducted on 11/08/22 at 10:55 AM with the Deputy who found Resident # 206 mid-morning on 10/27/2022. The Deputy reported that the call identified a missing adult/endangered, white male, about 60-years old, walking around with his pants down, exposing his buttocks. He said the resident was wearing a blue t-shirt and blue pants, that could be identified as scrubs. The resident was found near a park in a neighborhood, and he looked disoriented. The resident was able to tell him his name and date of birth, and then told the deputy that he was short of breath. The deputy reported that they called the EMS who took him to the hospital that he had been discharged from. Observation of the facility revealed it was a four story L shaped building on the corner of two main streets. The building's parking lot was adjacent to an outpatient building with roads leading past the building to the two main streets. Across the street from the facility was a major hospital with an ER and multiple entrances into the ER and parking lots. The entrance to the facility was approximately 88 feet from the Receptionist Desk, which included an entry hall of 26 feet, which ended in a T intersection. The Elevator was 42 feet from the intersection of the two halls and the reception desk another 20 feet from the elevator. The resident's room on the second floor was two doors down from elevator, with a nursing station in front of the elevators. The staffing sheet for 10/26/2022 did not list a unit manager on duty on the second floor, who would have worked from the nursing station. Two nurses and four aides were assigned to the 3-11 shift on the second floor. The census on the second floor on 10/26/2022 was 44 residents. Access to the resident floors, above the main floor, was by way of two elevators, both of which were in front of the nursing stations. The elevators had a coded access to enter on the second, third, and fourth floors. The code was not to be given to anyone, including medical professionals, vendors, or visitors. Only staff were to have the code and were to provide access to the elevators when an authorized person requested to leave the floor. The day, 10/26/2022, was warm and sunny with temperatures between a high of 79 and 82 degrees F between noon and 6 p.m., according to the website providing Past Weather in [NAME]. Overnight, the temperature ranged from 73 to 75 degrees F. It was a clear evening and night. The potential route that the resident took was identified as walking west out of the facility parking lot, and turning north on a four-lane road with a speed limit of 45 mph. The distance between the facility and the park where the Deputy found the resident was 5.1 miles along roads that ranged from two to four lane [TRUNCATED]

Based on interviews with Resident #206, a family member of Resident #206, facility staff, the Medical Director, and a Deputy with the local police department; a review of facility documents, including admission documents for Resident #206, hospital records for Resident #206, facility policies, and training documents; and observation of the facility entrance, the resident's room, and the potential route the resident took once he left the facility, it was determined that the facility failed to provide adequate supervision to one resident (Resident #206) of 4 residents sampled for accidents/supervision, when after less than 25 minutes in the facility, the resident was able to get on an empty elevator that had a coded entry to ensure resident's safety, ride the elevator to the ground floor and walk, unescorted and unimpeded out the front door of the facility. The resident's image was caught on camera at 3:52 p.m. on 10/26/2022 exiting the building, alone. Notification to Administrative Staff by the staff who were to supervise him occurred at 6:00 p.m., two hours after the resident's departure from the facility. Law Enforcement was not notified of the resident's unauthorized departure from the facility with location unknown until 6:47 p.m. Facility staff did not notify the hospital from which he had been discharged at 3:30 p.m. that afternoon, and which was across the street from the facility, until 8:30 p.m. The resident was not found until 10/27/2022 at 10:30 a.m.; 18.5 hours after he was observed, on camera, leaving the facility. It was determined that staff had not implemented their elevator protocol when Resident #206 was able to board an empty elevator, confirmed by no staff or visitor reporting they had seen or ridden down on the elevator with Resident #206, and walk out the front door with no staff questioning who he was or where he was going. This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and or death to Resident #206 and resulted in the determination of Immediate Jeopardy on 10/26/2022. The findings of Immediate Jeopardy were determined to be removed on 11/15/2022 and the severity and scope was reduced to a D. Findings included: Resident #206 had been living in a local Assisted Living Facility (ALF) prior to a hospitalization for increasing weakness. According to hospital records, the resident was admitted on [DATE] with a History and Physical (H&P) documented at 3:54 p.m. The H&P documented the patient as a [AGE] year-old male with past medical history significant for schizoaffective disorder, hypertension, seizure disorder and COPD [chronic obstructive pulmonary disease], presented to the emergency department via EMS [Emergency Medical Services] from his ALF with complaints of worsening weakness. Has extensive psychiatric history and on multiple medications for schizoaffective disorder. Currently patient lethargic and unable to give much history. Audible wheezing throughout his lung fields with poor air movement. The Hospital Course as documented in the Discharge Summary dated 10/26/2022 listed diagnoses as COPD with exacerbation with respiratory insufficiency, seizure disorder, schizoaffective disorder, bipolar type, hypertension, and metabolic versus toxic encephalopathy. Treatment during the hospital stay included a psychiatry consult that adjusted medications, resulting in the patient becoming combative and uncooperative on the day of discharge. Both a concern with a history of noncompliance and refusing medications at the ALF as well as a concern with being overmedicated due to lethargy were documented. Physical Therapy had been consulted. The patient was described as lacking insight and good judgement. Initially the discharge plan was to return to the ALF, but the ALF had reportedly felt the patient's needs could not be met at the ALF and they were recommending the resident admit to a skilled nursing facility. A review was conducted of the admitting documents from the hospital which included the 3008. On page 1 of 2 pages of the 3008, Section C. Decision making capacity (patient) was marked as requires a surrogate. Section D listed an Emergency Contact and phone number. Section E Medical Condition on the 3008 listed Weakness as the diagnosis. Section G Patient Risk Alerts listed falls. Page 2 of the 3008 Section S Physical Function identified the resident as ambulating independently, self-transfers, no devices in use (such as a wheelchair) and full weight bearing ability on left and right sides. Section U of the 3008 Mental/Cognitive Status at Transfer identified the resident as Alert, oriented, follows instructions. Another document sent in the admission packet the Pre-Admission Screening Tool, dated 10/25/2022, described the resident's current cognition level as A&Ox1-2 (alert and oriented x one to two). (Alert and oriented x 3 indicates an individual that is oriented to three axes, person, place, and time. The nurse documenting on the Pre-Admission Screening Tool did not explain which orientation the resident was missing.) The form described the resident as not confused and mobile as the form indicated a confused and mobile patient would be considered an elopement risk. There was no assistive device in use when he walked into the facility. The pre-admission screening did not list the resident as requiring oxygen. His mobility status was also described as ambulatory, with minimum assistance, with no weight bearing precautions and having had recent falls. Resident #206 was admitted to the facility on [DATE] at 3:29 p.m., as captured on video taken of the entrance of the facility. The resident was observed to walk into the building following the Transporter who led the resident to the Receptionist Desk. In an interview was conducted with the Admissions Coordinator on 11/06/2022 beginning at 12:05 p.m. she reported remembering when Resident #206 was admitted . She said she happened to be near the Receptionist's desk and saw a Transporter walking in with a resident walking behind him, with no assistive device. She said therapy was contacted for a wheelchair and once they brought a wheelchair to reception, Resident #206 sat down in it, and she took him up to his room. She confirmed he had admission paperwork with him. She reported once the resident was in his room, she assisted him into his bed and began to familiarize him with the room and his call bell. She said he seemed fine, and he didn't say much, including anything about having been admitted to the facility. She said that she let the nurse know her new admission had arrived and then she left the floor. She reported that she went home a few hours later but was called back in to assist in searching for Resident #206 as he didn't seem to be anywhere in the building. She confirmed assisting in the search, but they were not able to find him that night. She said she went home and when she returned the next morning, she learned his location was still unknown. In an interview conducted with the resident on 11/07/2022 beginning at 9:10 a.m., he confirmed he had walked out of the facility and ended up in a park. He confirmed he had been out all night and had had nothing to eat. With a laugh he said he was glad it hadn't rained that night. He reported he had been dropped off at the facility and could not remember how he got up to his room. He reported he had been lying in his bed, but then got up, walked into the hall and no one was around. He said the elevator came up, the door opened, and a staff member got out and walked away and he got onto the elevator. He reported the elevator took him to the first floor and he walked out the front door and no one said anything to him. He said he was trying to get back to his ALF, but he turned the wrong way and walked until he ended up in the park. He confirmed the police confronted him in the park due to what he was wearing, and he told the police that he was short of breath. He was taken back to the hospital that he had left the day before and remained until 11/01/2022 when he returned to his ALF. The History and Physical from Resident #206's second admission to the hospital, on 10/27/2022, documented his elopement from the facility, that he had been found by the police wandering, and found in respiratory distress, hypoxic, and therefore taken to the emergency room (ER). The resident had been discharged on [DATE] on room air, but on 10/27/2022 the doctor documented, despite drips and nebs (medication doses and nebulizer treatments) he remained wheezing and hypoxic. The exam in theER on [DATE] documented mild distress, the patient was not alert and oriented, but cooperative without the appropriate mood and affect. Observation of the facility revealed it was a four story L shaped building on the corner of two main streets. The building's parking lot was adjacent to an outpatient building with roads leading past the building to the two main streets. Across the street from the facility was a major hospital with an ER and multiple entrances into the ER and parking lots. The entrance to the facility was approximately 88 feet from the Receptionist Desk, which included an entry hall of 26 feet, which ended in a T intersection. The Elevator was 42 feet from the intersection of the two halls and the reception desk another 20 feet from the elevator. The resident's room on the second floor was two doors down from elevator, with a nursing station in front of the elevators. The staffing sheet for 10/26/2022 did not list a unit manager on duty on the second floor, who would have worked from the nursing station. Two nurses and four aides were assigned to the 3-11 shift on the second floor. The census on the second floor on 10/26/2022 was 44 residents. Access to the resident floors, above the main floor, was by way of two elevators, both of which were in front of the nursing stations. The elevators had a coded access to enter on the second, third, and fourth floors. The code was not to be given to anyone, including medical professionals, vendors, or visitors. Only staff were to have the code and were to provide access to the elevators when an authorized person requested to leave the floor. The day, 10/26/2022, was warm and sunny with temperatures between a high of 79 and 82 degrees F between noon and 6 p.m., according to the website providing Past Weather in [NAME]. Overnight, the temperature ranged from 73 to 75 degrees F. It was a clear evening and night. The potential route that the resident took was identified as walking west out of the facility parking lot, and turning north on a four-lane road with a speed limit of 45 mph. The distance between the facility and the park where the Deputy found the resident was 5.1 miles along roads that ranged from two to four lanes, some roads straight and some curvy, with sidewalks that changed from one side of the road to the other and sometimes ended in dirt paths. Walking north would have taken the resident past intersections that widened into multiple lanes with turn lanes. Speed limits ranged from 25 to 45 mph. The resident was seen leaving the facility at 3:52 p.m. on video. Shift change occurs at 3:00 p.m. and a smoking break for the residents is planned for 4:00 p.m. Residents are aware they can congregate at the back door to the smoking area on the first floor which is around the corner from the reception desk and elevator. The resident reported seeing no staff in the area around the elevator on the second floor, except for the staff member who exited the elevator and walked away from the elevator leaving the door open, and available for Resident #206 to enter, ride to the first floor, and walk out of the building, unnoticed. The resident reported no one on the first floor stopped him or asked where he was going. An interview was conducted with the resident's admitting nurse, RN HH (Registered Nurse) on 11/10/2022 beginning at 12:20 p.m. She confirmed she worked the 7-3 shift and then agreed to stay to cover the 3-11 shift on the second floor on 10/26/2022. She reported that the second floor is very busy, with no unit manager and two nurses with usually four or five aides. She reported she had three admissions and one discharge during her two shifts, with two of the admissions and the discharge occurring during the first shift. She reported the Director of Nurses (DON) helped her with one of the admissions and she was told the ADON (Assistant Director of Nurses) would help her with another admission, but then the new admission went missing. RN HH confirmed she worked the shorter hall, which has poor sight of the elevator, unless someone is standing right in front of it. She said the nurse who works on the longer hall can see into the elevator, to see who is getting onto it, but only if they are standing in the first part of the hall. She added when either nurse is passing medications, they go into the resident's room and then they can't monitor the elevator. RN HH said without a unit manager, the nurses or aides have to answer the phone at the nurses' station, input the elevator code for someone asking to leave the floor, and ensure that no one gets on the elevator that isn't supposed to. RN HH reported that the resident in (room #) was not doing well and she was on the phone with the doctor. She said the new resident in 212A, Resident #206, was in his bed when she was on the phone with the doctor, and she saw the resident get up out of bed and walk out of the room. She said she spoke to him, letting him know she was his nurse and he said good. She said he said nothing else to her. She said she took his temperature but not the other vitals as the equipment wasn't handy to her. She said he was friendly, clean, but looked more like a visitor than a resident. She said she got busy with the other sick resident and also busy passing medications to her other residents, and she didn't know Resident #206 had gotten onto the elevator and left the building. She said it wasn't until the aide told her that he wasn't in his room when they delivered the dinner trays that she knew he wasn't around. She said herself and one of the aides looked all around for him on the second floor without success. RN HH reported she never had the chance to review his medications or admitting paperwork. She denied that the resident told her that he didn't want to be there, and said he only responded to her saying that she was his nurse. She reported that she felt not having a third nurse or a unit manager to observe and assist with the residents was the reason the resident was able to leave the floor unobserved. When asked about staff training on the elevator protocol, she reported that staff are not to walk away from an open elevator as a resident could get onto it. She wasn't sure if that information was actually part of the training or not. A review of the job description for the Unit Manager, undated, revealed in the Summary of the Position, the Unit Manager, RN (UM-RN) is responsible for overseeing direct nursing care to assigned Residents/Patients. The UM-RN assumes responsibility and accountability for the nursing care and services provided on the assigned unit. The UM-RN is responsible for and adheres to the standards of care for assigned Residents/Patients, assists with data collection, monitoring and implementation of physician orders based on individual resident/patient needs, manages the environment to maintain resident/patient safety, and supervises the resident/patient care activity performance by licensed nurses and certified nursing assistants. Under Essential Duties and Responsibilities was a bullet point that read: Oversees the assessments of the resident/patient admission process. In an interview with facility staff on 11/14/2022 beginning at 9:30 a.m. the lack of a Unit Manager on the second floor was raised. The Administrator reported that a Unit Manager for the second floor had been hired. The DON reported that unit managers remain until 4 or 5 p.m. during the week and after that the charge nurse is available to assist the nurses on the floors. She reported that the Unit Managers work the day shift and assist with what needs to be done, including remaining at the nursing station to answer the phone and watch the elevator. She reported without a Unit Manager assigned to the floor, the other Unit Managers from the third and fourth floor were to assist and the DON and ADON were available also. An interview was conducted with the facility's Medical Director on 11/09/2022 beginning at 8:30 a.m. He reported that the Administrator had notified him of a resident who had left the facility unescorted, but he could not identify the day that he had been made aware. He reported that he agreed with the Administrator's decision that the resident was alert and oriented therefore she could not make him stay. When asked if the resident's surrogate should have been involved in a decision to leave the facility, he reported that would be best, but he had been told the resident left right away. He said the better way to leave would be for the resident to let his nurse know his plan to leave, sign a document and the nurse should write a note. In an interview with Staff R, Licensed Practical Nurse (LPN) on 11/07/2022 beginning at 9:15 a.m., the LPN reported that he knows not to let residents onto the elevator. He described another resident as watching the elevator and when that resident thinks he can sneak on to it, he self-propels his wheelchair quickly onto the elevator. He reported they try to have someone at the nursing station to watch the elevator to make sure a resident doesn't get on. He confirmed when staff are on the elevator, they need to ensure any resident that gets on the elevator is escorted or can say where he is going. He confirmed that staff are to ensure the elevator door closes prior to leaving the area to ensure no resident gets on the empty elevator. Staff S, RN was interviewed on 11/07/2022 beginning at 9:20 a.m. He reported that he was not aware of how the resident was able to leave the facility, but figured the resident was able to get onto the elevator with other residents and staff. An interview was conducted with Staff NN, Certified Nursing Aide (CNA) on 11/09/2022 beginning at approximately 12:00 p.m. She reported that she only works the 7 to 3 shift, and she wasn't at the facility when the new admission (Resident #206) arrived. She reported she had received training on the elevator in the past and knows not to give out the code. She reported that staff are told to only let residents onto the elevator that are with staff or if they know the resident is alert and oriented and allowed to leave the floor. She reported that some residents who are alert and oriented can sign out on the floor and leave the building and some of the smokers, being alert and oriented, are allowed to leave the floor unescorted as they are known to be going down to smoke. The Administrator was interviewed on 11/07/2022 beginning at 11:00 a.m. about Resident #206 and his ability to leave the facility 23 minutes after having arrived. She reported that the resident's absence was not considered an elopement as the resident was alert and oriented and had told staff he did not know he was coming to a rehab facility, and he didn't want to be at a rehab facility. The facility called their Code Silver (Missing Resident) Drill on 10/26/2022 at 6:06 to search inside the building for Resident #206. The Overview for the Missing Resident/Patient Action Plan read: To assist in guiding the facility with suggested activities in response to a missing resident/patient. The form is not intended as an all-inclusive list of actions, rather a prompt of some key areas to review or perform. The completed form was reviewed and noted that according to the Elopement Decision Tree, reporting to the state agency was not applicable. A review of the Elopement Decision Tree revealed the first question read: Did a resident /patient leave the premises or a safe area without authorization and/or necessary supervision and was resident at risk for harm or injury? The facility answered NO to this question which guided the facility to stop as this was not considered an elopement. When the Administrator was asked why the question was answered No, as the resident had left the premises, considered a safe area, without authorization or supervision and he was at risk for harm or injury, she reported, on 11/07/2022 in the interview that began at 11:00 a.m., that because the resident's admission documents from the hospital indicated he was alert and oriented and his own person, he had the authority to leave. The Administrator provided the guidance used when investigating an incident to determine whether the resident experienced harm as a result of the incident. The first bullet point asked whether the resident experienced physical, emotional, or mental injury. The facility's documented response read, no injury reported by law enforcement (LE) or hospital. When asked about this statement, the Administrator re-iterated that neither LE nor the hospital found any injury. There was no evidence of a mental health assessment in the hospital notes, so the answer No was not founded on any evidence of an assessment by social services or psychological staff. There was a question about the likelihood that the resident could have experienced physical, emotional, or mental injury to which the answer had been documented as No. As the resident had been away from the facility for 18.5 hours, overnight, there was some likelihood that the resident could have experienced physical, emotional, or mental injury. A question asked if the resident was at risk for being hit by a motor vehicle with the answer No, used sidewalks while exiting the premises. The location at which the resident was found was 5.1 miles away. Driving a potential, direct route from the facility to the location in the park where he was found revealed some areas of the route which ranged from narrow two-lane streets to wide busy four lane streets, some without sidewalks, intersections with traffic lights, and turn lanes. Observation of the photo of the resident arriving to the facility could not identify what the resident had on his feet. His pants were long and covered some of his feet, and it was difficult to identify whether the resident had soft moccasin like shoes on or only socks. The guidance document asked about appropriate clothing and the documentation read: resident was wearing long sleeved flannel shirt, long pants, and nonskid socks. There was nothing documented about shoes. A request was made for the facility policy on the timeline to complete a new admission assessment. The Administrator provided the policy, Admission/Readmission Data Collection, which read: The Resident's Admission/Readmission Data Collection will provide a comprehensive description of the Resident's status on admission. The assessment can be used for Residents who have left the facility and return with a significant change of condition. The assessment is designed to identify past history, current findings and factors that may put the Resident at risk. The baseline plan of care must be created in the system after completion of the assessment. Document in the Nurses Progress Notes every shift for a minimum of 72 hours on all new admissions to identify changes in status post admission. The entire admission/readmission data collection must be completed for the assessment to be comprehensive. The assessment must be completed within 72 hours of admission. The Administrator reported, in an interview conducted on 11/07/2022 beginning at 11:00 a.m., she had spoken with the resident on 10/27/2022 when he was at the hospital, and he told her that he was able to get onto the elevator when someone else got off. When a request was made for the policy or protocol for the secured, coded elevator, the Administrator provided an in-service that conducted on 10/27/2022 instead. She provided an in-service document dated 10/27/2022 with listed objectives and confirmed there wasn't a specific or formal policy for maintaining the safety of the elevator. The objectives of the in-service were: elevator code should not be shared with residents or families; any staff member who gives code to unauthorized persons will be subject to disciplinary action or possible termination; alarms should be checked and verified that residents are not exit seeking. Even though the resident told the Administrator that he was able to get onto the elevator when someone else got off, that information that staff need to watch the elevator door close before walking away to ensure a resident doesn't get onto it was not included in the in-service. In an interview that was conducted with the Administrator on 11/07/2022 beginning at 11:00 a.m., she confirmed in her review of the admitting documents that the resident was alert and oriented and his own person. She reported that his admitting nurse had reported that the resident told her that he didn't know he was being admitted to a rehab facility and he had wanted to go back to his ALF. She reported that he was able to leave the building based on his cognitive status; she couldn't refuse to let him leave as that would violate his rights. The Administrator reported a timeline that had been developed from the staff interviews and video of the resident arriving and leaving. She said that the resident was observed walking into the building at 3:29 p.m. and walking out of the building at 3:52 p.m. She confirmed that the resident's aide initially reported that the resident was not in his room when she went in to deliver his dinner tray. She reported she learned the resident's location was unknown at 6:00 p.m. at which time a Code Silver (Elopement protocol) was called, and staff were asked to conduct an internal search. She reported the internal search was conducted from 6:06 p.m. until 6:13 p.m. She said after learning that the resident was not located in the building, she sent staff out in pairs to drive around the vicinity to look for him. The Administrator confirmed that the initial search of the building took only 7 minutes due to many of the staff having been in the building and joining in the search. In a second interview with the Administrator on 11/14/2022 beginning at 9:30 a.m., when asked if a timeline had been developed from the staff interviews during the time the resident was in the building, the Administrator reported that none of the interviews indicated anyone took the elevator down with the resident, including staff and visitors, and no one admitted to having walked away from the elevator, leaving it open for the resident to get on and leave the floor. The Administrator reported that the Director of Nurses had phoned those visitors who had signed the visitor log on 10/26/2022 during the time period that Resident #206 had arrived at and then left the facility. The DON confirmed she was not able to contact every visitor, but no visitor said they rode down on the elevator with someone else. The question about how they accessed the elevator was not asked, so it is not known whether the elevator was standing open after someone else walked out of the elevator, or if they knew the code, or if someone had entered the code for them. There was no detailed timeline of who was on the second floor at what time, whether they were on the elevator, got off the elevator or who entered the elevator code to let the visitors off of the floor. The facility questioned visitors to the facility from 10/26/2022 about whether anyone rode in the elevator with them. The audit tool used to document visitor responses to their questioning about the late afternoon of 10/26/2022 only asked if someone rode down on the elevator with them. It didn't ask who input the code to allow them off the elevator, or if the elevator came up to the floor, someone got off which allowed them to get on. On 11/08/22 at 10:24 a.m., an interview was conducted with the Resident #206's family member. He confirmed he heard from the police on 10/26/22 at 10:30 p.m. and again on 10/27/22 at 7:00 am. about his missing brother. He reported that he did not hear from the facility that his family member was able to get out of the facility. The family member had been made aware of where the resident was found and reported that the resident can hardly walk and didn't know how he made it so far. He said even with his walker the resident was unstable and he didn't know if he had his walker with him. He had heard the resident went to the rehab facility and was able to leave from there, which seemed pretty easy. He confirmed he was told they didn't find him until the next morning and then they took him to the hospital. When asked about the resident's cognitive status, the family member reported the resident can make decisions, but his health is bad, so he needs help with medications. He confirmed the resident takes medications for schizophrenia. He reported he was hard to hear and understand as the resident talks so low. He reported the resident can make everyday decisions, but long-term or involved decisions, like understanding if he doesn't go to rehab, he may not be able to stay at the ALF, are hard for him. The family member reported that he told Resident # 206 to go to rehab or the ALF wouldn't take him back. He reported that the hospital never called him to let him know that they were sending the resident to a rehab facility. He confirmed he was the resident's Health Care Surrogate and Power of Attorney. An interview was conducted on 11/08/22 at 10:55 AM with the Deputy who found Resident # 206 mid-morning on 10/27/2022. The Deputy reported that the call identified a missing adult/endangered, white male, about 60-years old, walking around with his pants down, exposing his buttocks. He said the resident was wearing a blue t-shirt and blue pants, that could be identified as scrubs. The resident was found near a park in a neighborhood, and he looked disoriented. The resident was able to tell him his name and date of birth, and then told the deputy that he was short of breath. The deputy reported that they called the EMS who took him to the hospital that he had been discharged from. Admission documents received by the facility at the time Resident #206 arrived on 10/26/2022 included a list of medications that were ordered for the resident. Medications that the resident should have received before bed included Olanzapine 5 mg for Schizophrenia; Gabapentin 400 mg for neuropathy; Budesonide inhalation for wheezing and shortness of breath; Divalproex sodium 500 mg for seizures; Formoterol 2 ml inhalation for shortness of breath; Lorazepam 1 mg for anxiety; Melatonin 3 mg for insomnia; Metoprolol 25 mg for hypertension and Tizandinine 4 mg for muscle spasms. An interview was conducted on 11/08/22 at 11:50 a.m. with Staff P, RN who reported she was not aware that a resident had been able to leave the building unescorted. She reported that she doesn't usually work the short hall where the resident was admitted . She confirmed she had not received Elopement training recently. She was aware the elevator code changed about two weeks ago, and they are not to share the code with anyone. She reported they must enter the code for any resident or visitor that wants to get onto the elevator. She reported that she usually learned about new admissions any time during her shift. She said she would then let the aides know someone is coming and they arrive usually by the end of the shift. An interview was conducted on 11/08/22 at 12:00 p.m. with Staff L, an aide on the floor where Resident #206 was admitted . She reported that she was a float aide. She confirmed there were several Silver Alert drills in the last couple of weeks. She reported she wasn't at the facility on the day that the resident left. She hadn't heard any details about the resident and how he left. She confirmed she knows about the elevator and how they can't give the code out or let residents onto it, especially if you don't know the resident. On 11/08/22 at 12:15 p.m., Staff LL, an aide who reported she usually worked the 7-3 shift on the 200 floor was interviewed. She reported [TRUNCATED]

Based on record review and interview with the facility staff, the facility failed to provide interventions to provide care free of accident hazards for one (#4) of 3 residents sampled for falls which resulted in the resident's fall from the bed, during personal hygiene care, sustaining lacerations above the right eye with subsequent transfer to the hospital. Findings include: Resident #4 was a long term resident of the facility with [DIAGNOSES REDACTED]. A note documented on 06/17/14, at 9:48 a.m., by the Activities Department prior to the June Quarterly assessment revealed "Resident is alert with long term and short term memory deficits and severely impaired for decision making skills." The quarterly Minimum Data Set (MDS) assessment, completed on 03/27/14, identified the Resident as needing extensive assistance with bed mobility requiring two persons physical assist; total dependence with toileting (cleaning after an incontinent episode) requiring two persons physical assist, and extensive assist requiring two persons physical assist for personal hygiene. Interview with the MDS Coordinator, on 07/16/14 beginning at 4:00 p.m. confirmed that the care plan is developed from the assessment and the two should match. She referred to the quarterly MDS functional status section which coded the Resident as needing two staff to assist with bed mobility, toileting, and personal hygiene needs. She compared the MDS assessment to the ADL care plan and confirmed that the two did not match. The ADL care plan interventions indicated only one staff was needed to assist with bed mobility and personal hygiene while the MDS assessment completed on 03/27/14 indicated the Resident required two persons physical assist for bed mobility and personal hygiene. She confirmed that there was no indication of the number of staff required to assist for toileting included in the care plan, while the MDS Assessment indicated two persons providing physical assist would be needed. Review of the progress notes revealed on 06/29/14 written at 7:37 a.m., "called into the room by aide, Resident observed lying on the floor, face down. per aide she was giving care to the resident, while she rolled her to her side, Resident slid out of the bed and rolled on her back. laceration noted above and below right brow, moderate amount blood noted, Resident alert and no change of sensorium noted. Resident sent to hospital about 6 a.m." An interview was conducted on 07/16/14 beginning at 10:20 a.m. with the nursing aide, (aide C) who had been with the Resident providing morning care on 06/29/14 when the Resident slid from the bed. Aide C reported that she was giving the Resident a bed bath after providing incontinence care after a large bowel movement. She reported that she had rubbed baby oil on the Resident's skin, per the family's request, and then proceeded to reposition the Resident so she could continue rubbing baby oil on the Resident's skin. She reported that she pulled the draw sheet with the Resident closer to her and pulled soiled wet sheets and the gown from under the Resident to discard them. She said that the Resident began to slip away from her, probably because of the gloves that she had on while providing care, which were slippery with baby oil. She said that she was able to grab the Resident's legs, but because the Resident's arms were contracted and were held up against her chest, the Resident is top heavy. The aide reported that she was not able to get a better grip on the Resident and she could not prevent the Resident from slipping off of the bed onto the floor. She said that she had been calling for assistance once the Resident started to slip off of the bed, but when the Resident fell to the ground, she ran out of the room calling for someone to help. She confirmed that a nurse entered the room and together they saw that the Resident was bleeding from cuts above and below her right eye. She said that she thought the Resident fell on to the base of the tube feeding pole, as they had to pull the pole out from underneath the Resident to be able to lift the Resident back into the bed. Aide C confirmed that she always provided care to the Resident by herself, without assistance from another aide. She confirmed that the Resident's arms were bent at the elbows, and the contractures caused the Resident to hold her upper arms alongside her body with her hands under her chin. She reported that the Resident's legs and hips were thin, causing the Resident to be "top heavy." She confirmed that she provided all care to the Resident by herself, without calling another aide to assist. She said the family would ask for her to provide care to the Resident and would stay in the room and talk with her when she cared for the Resident. Interview with nursing aide A, on 07/16/14 beginning at 2:50 p.m., revealed that she had frequently worked with Resident #4 during the day shift. She reported that Resident #4 was not able to assist during ADL care, explaining that the Resident had contractures to both arms, resulting in the Resident holding her arms bent at the elbow, held against her chest, with her hands under her chin. The aide reported that the Resident did not understand and was not able to physically hold the side rail to assist in holding her position in bed. She said she always waited for a second aide to assist her when she provided care to the Resident as she was not able to care safely for the Resident alone. She reported that she wasn't comfortable positioning the Resident to lie on her side, down the middle of the bed, with no one to hold her in place while she provided incontinence care. This aide was also questioned about the use of the baby oil on the Resident's skin. The aide reported that she didn't use much oil, and while holding her hands together, and then moving them in opposite directions quickly, she demonstrated that "it made the Resident too slippery." An interview with nursing aide B, on 07/16/14 beginning at 4:40 p.m. revealed that he remembered Resident # 4 and confirmed that he frequently provided care to the Resident. The aide was asked to describe the care he provided to the Resident. The aide began his description by saying, "first I wait until someone will help me." The aide reported that the Resident was heavy and did not participate in the care. He described the Resident's contracted arms, and reported that it made her hard to move alone. He reported that he could not clean the Resident; provide incontinent care, or anything without a second aide. An interview with the Risk Manager, on 07/15/14 beginning at 1:45 p.m., revealed she had conducted an investigation into the fall from the bed by Resident #4. She reported that the aide had confirmed that she provided care to the resident unassisted, and blamed the baby oil, requested to be used by the Resident's family, as leading to the cause of the slip from the aides' hands and the fall. On 07/17/14 at approximately 12:15 p.m. the Corporate Nurse, Administrator and Director of Nurses reported that they develop the care plans from the care the aides give to the Resident, not the MDS assessment. Since most aides documented the use of one aide, not two, to provide care to Resident #4, it was okay that Aide C provided care to the Resident by herself. They did not see the care plan as having to be developed from the assessment. They reported that the care plan is based on the care the aides provide to the resident, rather than the assessment that is developed from the Interdisciplinary Team.

Based on observations, staff interview, facility record review and policy review, the facility failed to ensure that residents with special care needs were properly supervised and attended to due to three staff members, who were found sleeping (A., B. and C.). The staff included two L.P.N.s and one aide, sleeping on one 11-7 shift , on two of three units (second and fourth). Additionally, the failure of one of two nurses (Employee E) to properly supervise the activities of Employee A contributed to the threat that care needs would not be met. This practice increased the likelihood that staff would not be available to respond to the care needs on two of three units (Second and Fourth) for fifty-two of one hundred and sixty-three residents (#1 through #52), which resulted in findings of Immediate Jeopardy, which was removed 5/5/12. Findings include: 1. Review of the current L.P.N. job description, provided by the facility on 5/3/2012, found the following: "Assumes responsibility and accountability for assigned residents/patients for a shift of duty to ensure that the highest degree of quality care is maintained at all times", and "manages the environment to maintain resident/patient safety and supervise the resident/patient care activity performance by nursing assistants". The essential duties and responsibilities for the Licensed Practical Nurse delineated in the position description revealed to: "Conducts frequent rounds to monitor residents/patient conditions and ensure nursing personnel are performing their work assignments in accordance with acceptable nursing standards." 2. Review of the R.N. job description, provided by the facility on 5/18/2012 revealed the following language denoting responsibilities as: Section I. under the supervision of the Director of Nursing, a Registered Nurse supervisor assumes responsibility and accountability for a group of residents/patients for a shift of duty. Section A. Essential Functions of this job description under part b. indicated she directs the work of employees, part h. she enforces facility policies with authority to issue Disciplinary Action Reports as needed, part i. revealed she had Authority to suspend employees for rules violation. Page 2 under part #2 revealed she makes frequent rounds to note resident/patient conditions and to ensure nursing personnel are performing their work assignments in accordance with acceptable nursing standards, part #6 revealed she handles on-call responsibilities as required, part #7 revealed she provides the following functions, section a. is responsible for resident/patient car during his/her respective shift, section m. provides resident/patient care as needed. Page 3 under #14 indicated the nurse will comply with laws and regulations applicable to position and acts in accordance with the company ' s Corporate Compliance Program, #15 will treat all residents, visitors, and staff with courtesy, #20 safety part a. Knows and follows facility rules, part d. Reports and documents any incidents or accidents of residents, staff or visitors to the appropriate facility personnel. #21, Resident Rights under part a. Knows Resident Rights. Help the resident/patient exercise and/protect their rights." 3. The FACILITY EMPLOYEE HANDBOOK (undated), provided on 5/18/2012 by the facility, under "Work Rules and General Information," identified the following standards of conduct on page 25 including: "All employees must: Not violate the rights of residents; ensure residents are treated with dignity; not be negligent in the performance of assigned job duties; not sleep on duty." 4. On 5/3/2012 at 2:30 a.m. the survey team arrived at the facility and, after gaining entrance, accessed the elevator to the residential floors. The team proceeded to the elevator and went to the second floor. At approximately 3:01 a.m., when the doors opened on the second floor, there were two staff members at the desk. One being the shift supervisor, who was notified of the nature of the visit and the other being a nurse, L.P.N. (employee B), who was observed seated in a chair with her back turned to the telephone and door bell/speaker/monitor system and with her head on several books on the desk and with a blanket over her. It was observed that employee B was sleeping. The employee was not observed to wake up until approximately one to two minutes after arriving at the unit station. There were no odors or other indications of unmet care needs, however, at the time of the tour. 5. After that observation, the elevator was taken to go to the fourth floor. At approximately 3:06 a.m. when the elevator doors opened, there were two nurses observed at the nurse's station. One of those nurses, L.P.N. (Employee C.) was observed with her head laying on the desk with a blanket over her. Employee C. did not wake up immediately when this surveyor identified himself to the nurse that was awake and the reason why the surveyor was there. When employee C, a L.P.N., was asked why she was sleeping, she didn't answer. According to the 7 pm - 7 am for 5/2-5/3/2012 "C.N.A. Assignment" sheet and the 5/3/12 "Detail Census Report," Employee C was assigned two C.N.A.s who covered Rooms 422A through through 429B for a total of 26 residents. Immediately after this observation on 5/3/2012, the fourth floor dining room was observed with the main lights off and with the television on. Further observations revealed pillows and blankets on several of the chairs and on the couch. It was further observed when looking into the dining room, Employee A was in a chair with a blanket and pillow sleeping. The employee overheard other staff talking while the surveyor entered the dining room. She then awoke and got up and left the dining room. When employee A was asked her name and why she was sleeping, she only gave her name and didn't answer as to why she was sleeping and not working. There were no odors or other indications, however, of unmet care needs at the time of the tour. Review of the 5/2-5/3/2012 "C.N.A. Assignment Sheet" revealed Employee A was a C.N.A. assigned to care for residents living in Rooms 410 through 421. Continued review of the 5/2-5/3/2012 "C.N.A. Assignment Sheet" for the Fourth floor revealed that Employee (R.N.) was the R.N. Supervisor. Employee E, then, was not following her job description of supervision of the nurse and aide who were both sleeping, and by that, not ensuring a total of thirty-nine residents on this unit (Fourth floor) were adequately monitored and supervised for care needs. According to the 7 pm - 7 am for 5/2-5/3/2012 "C.N.A. Assignment" sheet, Employee E was assigned two C.N.A.s who covered Rooms 401A through through 421B. Employee A (C.N.A.) was assigned Rooms 410-421, per the "Detail Census Report" for 5/3/2012. Interview on 5/18/2012 at approximately 1:00 p.m. with the corporate regional vice president and regional director of clinical services revealed that the registered nurse on each floor/unit holds ultimate supervisory authority for all staff on that floor/unit. Review of the 5/2/12 - 5/3/12 Assignment Sheet for 7:00 p.m. - 7:00 a.m. revealed Employee E was the RN supervisor holding responsibility on the 4th floor for LPN/Employee C and C.N.A. A. 6. During the observations, the two nurses, both L.P.N.s, (employees B and C) were not able to perform their duties and supervise other staff members while sleeping: A. Review of the facility 672, completed on 5/3/2012, as well as the 5/3/2012, "Detail Census Report-Part 2 Listing by Room" for residents on "Hall 200" and the assignment sheet of that date, detailed the resident special care needs as follows for those assigned to Employee B: 1. Resident # 1 had special care needs of injections, respiratory treatment, treatment for [REDACTED]. 2. Resident # 2 had a special care need of respiratory treatment. 3. Resident # 3 had a special care need of suctioning as needed. 4. Resident # 5 had a special care needs of respiratory treatment and management of pain. 5. Resident # 6 had special care needs of respiratory treatment and pressure sores. 6. Resident # 7 had special care needs of incontinence of bowel and bladder, injections, and pain management. 7. Resident #8 had a special care need of catheter care. 8. Resident # 9 had special care needs of incontinence of bowel and bladder, respiratory treatment, injections, and pain management. 9. Resident # 10 had a care need of bowel incontinence and injections. 10. Resident # 11 had care needs of bowel and bladder incontinence. 11. Resident # 12 had tube feeding as a special care need. 12. Resident # 13 had a special care need of pain management. 13. Resident # 4 had a care need of supervision. B. Review of the facility 672, completed on 5/3/2012, as well as the 5/3/2012, "Detail Census Report-Part 2 Listing by Room" for residents on "Hall 400" and the assignment sheet of that date, detailed the resident special care needs as follows for those assigned to Employees C (L.P.N.) and A(C.N.A.): 14. Resident # 14 had special care needs of catheter care and pressure sores. 15. Resident # 15 had special care needs of incontinence of bowel and bladder. 16. Resident # 16 had special care needs of incontinence of bowel, management of pain, and injections. 17. Resident # 17 had special care needs of catheter care, incontinence of bowel, pressure sores, and pain management. 18. Resident # 18 had special care needs of incontinence of bowel and bladder, and respiratory treatment. 19. Resident # 19 had special care needs of incontinence of bowel and respiratory treatment. 20. Resident # 20 had a special care need of tube feeding and supervision. 21. Resident # 21 had a special care need of pain management. 22. Resident # 22 had special care needs of incontinence of bowel and pain management. 23. Resident # 23 had special care needs of incontinence of bladder and injections. 24. Resident # 24 had special care needs of incontinence of bowel, pain management, and respiratory therapy. 25. Resident # 25 had special care needs of catheter care, incontinence of bladder and bowel, pain management, injections, and respiratory therapy. 26. Resident # 26 had care needs of incontinence of bowel and bladder and supervision. 27. Resident # 27 had care needs of incontinence of bowel and bladder and supervision. 28. Resident # 28 had care needs of incontinence of bowel, injections, and supervision. 29. Resident # 29 had care needs of end of life treatment and was incontinent of bowel. 30. Resident # 30 had care needs of incontinence of bladder, management of pain, and was bedfast. 31. Resident # 31 had care needs of incontinence of bowel and bladder, pain management, injections, and respiratory treatment. 32. Resident # 32 had care needs of incontinence of bowel and bladder, injections and was bedfast. 33. Resident # 33 had care needs of incontinence of bowel and bladder and pain management. 34. Resident # 34 had care needs of catheter care, incontinence of bowel, and tube feeding. 35. Resident # 35 had care needs of respiratory treatment. 36. Resident # 36 had care needs of injections. 37. Resident # 37 had care needs of incontinence of bowel, pain management, and injections. 38. Resident # 38 had incontinence of bowel and bladder and needed supervision. 39. Resident # 39 had care needs of incontinence of bowel and supervision. 40. Resident # 40 had care needs of incontinence of bowel and bladder, tube feeding, and injections. 41. Resident # 41 had care needs of incontinence of bowel and bladder, pain management, injections, [MEDICAL TREATMENT], and supervision. 42. Resident # 42 had care needs of incontinence of bowel and bladder and supervision. 43. Resident # 43 had care needs of incontinence of bowel, respiratory treatment, and supervision. 44. Resident # 44 had care needs of urinary incontinence and supervision. 45. Resident # 45 had care needs of incontinence of bowel and bladder and supervision. 46. Resident # 46 had care needs of urinary incontinence and supervision. 47. Resident # 47 had care needs of incontinence of bowel and bladder and supervision. 48. Resident # 48 had care needs of incontinence of bladder and supervision. 49. Resident # 49 had care needs of incontinence of bladder and bowel and injections. 50. Resident # 50 had care needs of incontinence of bladder and supervision. 51. Resident # 51 had care needs of incontinence of bladder, pressure sores, tube feeding, injections, and respiratory treatment. 52. Resident # 52 had care needs of injections and tube feeding. 7. Review of the facility event log for the date of 5/3/2012 found no references to events which occurred on the 11pm-7am shift for 5/2-5/3/2012. 8. At approximately 4:00 a.m. the DON was made aware of staff sleeping during working hours of this 11-7 shift. The DON was asked if that is the normal practice on this shift, and she revealed that it was not practice to be sleeping at all during any part of a working shift. It was confirmed by the DON that employee A (C.N.A.) was responsible for thirteen residents on her shift and if sleeping, would not be able to answer call lights and provide care and services as needed, even during this shift when residents are normally sleeping. 9. Review of the Certified Nursing Aide (CNA) position description revealed under essential duties and responsibilities to: "Follow work assignments, and/or work schedules in completing and performing assigned tasks", "Perform all assigned tasks in accordance with the facility's established policies and procedures, and as instructed by supervisors", "Cooperate with inter-departmental personnel, as well as other facility personnel to ensure that nursing services can be adequately maintained to meet the needs of the residents", and to "Check each resident routinely to ensure that his/her personal care needs are being met in accordance with his/her wishes." 10. Interview on 5/18/12 at approximately 1:00 p.m. with the corporate regional vice president for the facility revealed she was called in to take over operational responsibility for the facility on 5/3/12 immediately following the complaint investigation. The clinical team reviewed documentation to determine whether there had been any incidents or adverse events related to the 11:00 p.m. - 7:00 a.m. shift and there was not any noted. On 5/3/12, all staff identified during the complaint survey was suspended pending investigation. On 5/15/12 all of the staff involved in the deficiencies received a written disciplinary action report and were terminated from employment. (Review of the time sheets for the staff members identified in the deficiency statement revealed 5/3/12 was their last day worked). Rounds were made in the facility on 5/3/12 and continue on a daily basis to ensure staff has all supplies necessary to care for the residents and the needs of the residents are being met. Staffing was reviewed by the DON to ensure that there was adequate staff to meet the clinical needs of the residents. The facility has hired an RN weekend supervisor responsible for the entire building on the night shift. The facility is currently interviewing applicants for a RN night shift supervisor position for Monday - Friday. At 8:00 a.m. on 5/4/12 a department head meeting was held to review the pending deficiencies from the complaint survey. It was imperative that all management staff felt the urgency to ensure professional standards were in place while delivering care to the residents. Audit tools were developed and implemented. These audit tools are used on each shift and are on-going as part of the quality assurance program. The regional vice president in coordination with the facility ' s management team developed the following action plan: Immediately upon exit of the surveyors on 5/3/12, in-servicing was initiated. This in-servicing continued on every shift until all regularly scheduled staff members were re-educated. All 101 regularly scheduled staff members had completed the in-service by 5/5/12. The following information was covered in the in-service: A. Building Access: 1. Monitor on 2nd floor must be on and volume on high at all times. No staff is to adjust the volume of the monitor. 2. Phones must be turned over to night shift daily at 8 p.m. by the receptionist. 3. All staff is to answer phones within the 1st 3 rings and respond and let people in the facility timely. B. Dignity: surveyor heard staff curse in front of a resident. 1. All staff must be professional and respectful around residents. 2. No cussing or speaking Spanish is to be done around residents. 3. Spanish should only be used if speaking to a Spanish speaking resident. C. Professional standards: 2 surveyors observed two nurses sleeping, one on the 2nd floor and one the 4th floor, in addition to a C.N.A. and a Nurse Supervisor were not monitoring staff. 1. Termination will be the outcome if a staff member is caught sleeping on the clock! Staff re-educated on the employee handbook as it relates to assigned responsibilities. D. [MEDICAL CONDITION] Care supplies: 1. [MEDICAL CONDITION] bags are to be in the room in the drawer at the bedside. Backup is in the supply room. If you use the last bag in the room you need to replace from the storage room. If you take the last one from the storage room you need to notify the supervisor and document it on the 24 hour report. E. Infection Control: 1. Isolation set ups over the doors must be stocked up at all times and restocked each shift. Personal belongings of staff need to be in lockers not on the units. All staff needs to empty their lockers at the end of the shift for the oncoming shift. The immediate jeopardy was removed and the scope and severity reduced to an "E."

Based on observations, facility file & record review and staff interview, the facility failed to ensure two of six Licensed Practical Nurses (employees B and C) and one of two (Employee E) Registered Nurses performed their duties and responsibilities and carried out professional standards to meet the needs of residents on two of three units (second, fourth). Employees B and C were both observed sleeping at the nurse's stations during the 11-7 shift and Employee E failed to provide oversight of a C.N.A. who was found sleeping in the dining room, which left 52 of 163 residents (#1-52) without the level of supervision necessary to respond to all emergent and non-emergent care needs. This practice resulted in findings of immediate jeopardy which was removed on 5/5/2012. Findings include: 1.3)(a) "Practice of professional nursing" means the performance of those acts requiring substantial specialized knowledge, judgment, and nursing skill based upon applied principles of psychological, biological, physical, and social sciences which shall include, but not be limited to: 1. The observation, assessment, nursing diagnosis, planning, intervention, and evaluation of care; health teaching and counseling of the ill, injured, or infirm; and the promotion of wellness, maintenance of health, and prevention of illness of others. 2. The administration of medications and treatments as prescribed or authorized by a duly licensed practitioner authorized by the laws of this state to prescribe such medications and treatments. 3. The supervision and teaching of other personnel in the theory and performance of any of the above acts. (b) "Practice of practical nursing" means the performance of selected acts, including the administration of treatments and medications, in the care of the ill, injured, or infirm and the promotion of wellness, maintenance of health, and prevention of illness of others under the direction of a registered nurse, a licensed physician, a licensed osteopathic physician, a licensed podiatric physician, or a licensed dentist. The professional nurse and the practical nurse shall be responsible and accountable for making decisions that are based upon the individual's educational preparation and experience in nursing. 2. On 5/3/2012 at 2:30 a.m. the survey team arrived at the facility and went to various entrance doors to try and get in. All doors were observed locked with one entrance door having a door bell/speaker/monitor on the wall next to it. After the door bell was rung at least twenty times and the facility main telephone line was called approximately ten to fifteen times during a thirty minute timeframe, the door was pulled with the alarm sounding for fifteen seconds until the safety mechanism allowed for the door to open. 3. At that time the survey team proceeded to the elevator and went to the second floor. At approximately 3:01 a.m., when the doors opened, there were two staff members at the desk. One being the shift supervisor, who was notified of the nature of the visit and the other being a L.P.N. (employee B), who was observed seated in a chair with her back turned to the telephone and door bell/speaker/monitor system. Employee B's head was on several books on the desk and she had a blanket over her. Employee B was observed sleeping. The employee was not observed to wake up until approximately one to two minutes after arriving at the unit station. There were no odors or other indications of unmet care needs at the time of the tour. 4. After that observation, the elevator was taken to go to the fourth floor. At approximately 3:06 a.m. when the elevator doors opened, there were two nurses observed at the nurse's station. One of those nurses, a L.P.N. (Employee C.) was observed with her head laying on the desk with a blanket over her. Employee C did not wake up immediately when this surveyor identified himself to the nurse that was awake and the reason why the surveyor was there. There were no odors or other indications of unmet care needs at the time of the tour. 5. Immediately after this observation on 5/3/2012, the fourth floor dining room was observed with the main lights off and with the television on. Further observations revealed pillows and blankets on several of the chairs and on the couch. It was further observed when looking into the dining room, Employee A was in a chair with a blanket and pillow sleeping. The employee overheard other staff talking while the surveyor entered the dining room. She then awoke and got up and left the dining room. When employee A was asked her name and why she was sleeping, she only gave her name and didn't answer as to why she was sleeping and not working. Review of the 5/2-5/3/2012 7 pm- 7am "C.N.A. Assignment Sheet" reflected that Employee A was one of two C.N.A.s assigned to Employee E (R.N.) that evening. 6. Interview on 5/18/2012 at approximately 1:00 p.m. with the corporate regional vice president and regional director of clinical services revealed that the registered nurse on each floor/unit holds ultimate supervisory authority for all staff on that floor/unit. Review of the 5/2/12 - 5/3/12 Assignment Sheet for 7:00 p.m. - 7:00 a.m. revealed Employee E was the RN supervisor holding responsibility on the 4th floor for LPN/Employee C and C.N.A. A. 7. Review of the Licensed Practical Nurse (LPN) job description revealed summary of position: "assumes responsibility and accountability for assigned residents/patients for a shift of duty to ensure that the highest degree of quality care is maintained at all times", and "manages the environment to maintain resident/patient safety and supervise the resident/patient care activity performance by nursing assistants". The essential duties and responsibilities for the Licensed Practical Nurse delineated in the position description revealed to: "Conduct frequent rounds to monitor residents/patient conditions and ensure nursing personnel are performing their work assignments in accordance with acceptable nursing standards". It was evident through observations, employees B and C who were both sleeping, were not performing their duties as per the job description and not supervising their aids who were also sleeping during the work shift. As a result of employees B and C not performing their duties, they were not meeting the needs of care and services, affecting residents on two of three units. 8. Review of the R.N. job description, provided by the facility on 5/18/2012 revealed the following language denoting responsibilities as: Section I. under the supervision of the Director of Nursing, a Registered Nurse supervisor assumes responsibility and accountability for a group of residents/patients for a shift of duty. Section A. Essential Functions of this job description under part b. indicated she directs the work of employees, part h. she enforces facility policies with authority to issue Disciplinary Action Reports as needed, part i. revealed she had Authority to suspend employees for rules violation. Page 2 under part #2 revealed she makes frequent rounds to note resident/patient conditions and to ensure nursing personnel are performing their work assignments in accordance with acceptable nursing standards, part #6 revealed she handles on-call responsibilities as required, part #7 revealed she provides the following functions, section a. is responsible for resident/patient car during his/her respective shift, section m. provides resident/patient care as needed. Page 3 under #14 indicated the nurse will comply with laws and regulations applicable to position and acts in accordance with the company ' s Corporate Compliance Program, #15 will treat all residents, visitors, and staff with courtesy, #20 safety part a. Knows and follows facility rules, part d. Reports and documents any incidents or accidents of residents, staff or visitors to the appropriate facility personnel. #21, Resident Rights under part a. Knows Resident Rights. Help the resident/patient exercise and/protect their rights." 9. During the observations, the two nurses, both L.P.N.s, (employees B. and C.) were not able to perform their duties and supervise other staff members while sleeping: A. Review of the facility 672, completed on 5/3/2012, as well as the 5/3/2012, "Detail Census Report-Part 2 Listing by Room" for residents on "Hall 200" and the assignment sheet of that date, detailed the resident special care needs as follows for those assigned to Employee B: 1. Resident # 1 had special care needs of injections, respiratory treatment, treatment for [REDACTED]. 2. Resident # 2 had a special care need of respiratory treatment. 3. Resident # 3 had a special care need of suctioning as needed. 4. Resident # 5 had a special care needs of respiratory treatment and management of pain. 5. Resident # 6 had special care needs of respiratory treatment and pressure sores. 6. Resident # 7 had special care needs of incontinence of bowel and bladder, injections, and pain management. 7. Resident #8 had a special care need of catheter care. 8. Resident # 9 had special care needs of incontinence of bowel and bladder, respiratory treatment, injections, and pain management. 9. Resident # 10 had a care need of bowel incontinence and injections. 10. Resident # 11 had care needs of bowel and bladder incontinence. 11. Resident # 12 had tube feeding as a special care need. 12. Resident # 13 had a special care need of pain management. 13. Resident # 4 had a care need of supervision. B. Review of the facility 672, completed on 5/3/2012, as well as the 5/3/2012, "Detail Census Report-Part 2 Listing by Room" for residents on "Hall 400" and the assignment sheet of that date, detailed the resident special care needs as follows for those assigned to Employees C (L.P.N.) and A(C.N.A.): 14. Resident # 14 had special care needs of catheter care and pressure sores. 15. Resident # 15 had special care needs of incontinence of bowel and bladder. 16. Resident # 16 had special care needs of incontinence of bowel, management of pain, and injections. 17. Resident # 17 had special care needs of catheter care, incontinence of bowel, pressure sores, and pain management. 18. Resident # 18 had special care needs of incontinence of bowel and bladder, and respiratory treatment. 19. Resident # 19 had special care needs of incontinence of bowel and respiratory treatment. 20. Resident # 20 had a special care need of tube feeding and supervision. 21. Resident # 21 had a special care need of pain management. 22. Resident # 22 had special care needs of incontinence of bowel and pain management. 23. Resident # 23 had special care needs of incontinence of bladder and injections. 24. Resident # 24 had special care needs of incontinence of bowel, pain management, and respiratory therapy. 25. Resident # 25 had special care needs of catheter care, incontinence of bladder and bowel, pain management, injections, and respiratory therapy. 26. Resident # 26 had care needs of incontinence of bowel and bladder and supervision. 27. Resident # 27 had care needs of incontinence of bowel and bladder and supervision. 28. Resident # 28 had care needs of incontinence of bowel, injections, and supervision. 29. Resident # 29 had care needs of end of life treatment and had incontinence of bowel. 30. Resident # 30 had care needs of incontinence of bladder, management of pain, and was bedfast. 31. Resident # 31 had care needs of incontinence of bowel and bladder, pain management, injections, and respiratory treatment. 32. Resident # 32 had care needs of incontinence of bowel and bladder, injections and was bedfast. 33. Resident # 33 had care needs of incontinence of bowel and bladder and pain management. 34. Resident # 34 had care needs of catheter care, incontinence of bowel, and tube feeding. 35. Resident # 35 had care needs of respiratory treatment. 36. Resident # 36 had care needs of injections. 37. Resident # 37 had care needs of incontinence of bowel, pain management, and injections. 38. Resident # 38 had incontinence of bowel and bladder and needed supervision. 39. Resident # 39 had care needs of incontinence of bowel and supervision. 40. Resident # 40 had care needs of incontinence of bowel and bladder, tube feeding, and injections. 41. Resident # 41 had care needs of incontinence of bowel and bladder, pain management, injections, [MEDICAL TREATMENT], and supervision. 42. Resident # 42 had care needs of incontinence of bowel and bladder and supervision. 43. Resident # 43 had care needs of incontinence of bowel, respiratory treatment, and supervision. 44. Resident # 44 had care needs of urinary incontinence and supervision. 45. Resident # 45 had care needs of incontinence of bowel and bladder and supervision. 46. Resident # 46 had care needs of urinary incontinence and supervision. 47. Resident # 47 had care needs of incontinence of bowel and bladder and supervision. 48. Resident # 48 had care needs of incontinence of bladder and supervision. 49. Resident # 49 had care needs of incontinence of bladder and bowel and injections. 50. Resident # 50 had care needs of incontinence of bladder and supervision. 51. Resident # 51 had care needs of incontinence of bladder, pressure sores, tube feeding, injections, and respiratory treatment. 52. Resident # 52 had care needs of injections and tube feeding. 10. Review of the facility event log for the date of 5/3/2012 found no references to events which occurred on the 11pm-7am shift for 5/2-5/3/2012. 11. Interview with the Director of Nursing (DON) at approximately 4:00 a.m. revealed nursing staff should not be sleeping during any part of their shift and should also be supervising Certified Nursing Aide staff to ensure they perform their duties and not sleep during working shift as well. 12. Interview on 5/18/12 at approximately 1:00 p.m. with the corporate regional vice president for the facility revealed she was called in to take over operational responsibility for the facility on 5/3/12 immediately following the complaint investigation. The clinical team reviewed documentation to determine whether there had been any incidents or adverse events related to the 11:00 p.m. - 7:00 a.m. shift and there was not any noted. On 5/3/12, all staff identified during the complaint survey was suspended pending investigation. On 5/15/12 all of the staff involved in the deficiencies received a written disciplinary action report and were terminated from employment. (Review of the time sheets for the staff members identified in the deficiency statement revealed 5/3/12 was their last day worked). Rounds were made in the facility on 5/3/12 and continue on a daily basis to ensure staff has all supplies necessary to care for the residents and the needs of the residents are being met. Staffing was reviewed by the DON to ensure that there was adequate staff to meet the clinical needs of the residents. The facility has hired an RN weekend supervisor responsible for the entire building on the night shift. The facility is currently interviewing applicants for a RN night shift supervisor position for Monday - Friday. At 8:00 a.m. on 5/4/12 a department head meeting was held to review the pending deficiencies from the complaint survey. It was imperative that all management staff felt the urgency to ensure professional standards were in place while delivering care to the residents. Audit tools were developed and implemented. These audit tools are used on each shift and are on-going as part of the quality assurance program. The regional vice president in coordination with the facility ' s management team developed the following action plan: Immediately upon exit of the surveyors on 5/3/12, in-servicing was initiated. This in-servicing continued on every shift until all regularly scheduled staff members were re-educated. All 101 regularly scheduled staff members had completed the in-service by 5/5/12. The following information was covered in the in-service: A. Building Access: 1. Monitor on 2nd floor must be on and volume on high at all times. No staff is to adjust the volume of the monitor. 2. Phones must be turned over to night shift daily at 8 p.m. by the receptionist. 3. All staff is to answer phones within the 1st 3 rings and respond and let people in the facility timely. B. Dignity: surveyor heard staff curse in front of a resident. 1. All staff must be professional and respectful around residents. 2. No cussing or speaking Spanish is to be done around residents. 3. Spanish should only be used if speaking to a Spanish speaking resident. C. Professional standards: 2 surveyors observed two nurses sleeping, one on the 2nd floor and one the 4th floor, in addition to a C.N.A. and a Nurse Supervisor were not monitoring staff. 1. Termination will be the outcome if a staff member is caught sleeping on the clock! Staff re-educated on the employee handbook as it relates to assigned responsibilities. D. [MEDICAL CONDITION] Care supplies: 1. [MEDICAL CONDITION] bags are to be in the room in the drawer at the bedside. Backup is in the supply room. If you use the last bag in the room you need to replace from the storage room. If you take the last one from the storage room you need to notify the supervisor and document it on the 24 hour report. E. Infection Control: 1. Isolation set ups over the doors must be stocked up at all times and restocked each shift. Personal belongings of staff need to be in lockers not on the units. All staff needs to empty their lockers at the end of the shift for the oncoming shift. The immediate jeopardy was removed and the scope and severity reduced to an "E."

Based on observations, staff interview, record review, and review of staffing schedules revealed the facility failed to ensure adequate staffing supervision to meet the needs of fifty-two residents (#1-52) of 163 residents during one shift (11-7). The facility scheduled seven nurses and eleven Certified Nursing Assistants from approximately 7:00 p.m. to 7:00 a.m. on 5/3/2012 based on the complex care needs of all facility residents. Observations revealed two of these seven nurses (Employees B and C) and one of these eleven Certified Nursing Aides (Employee A) were sleeping while on duty on two of four floors (Second and Fourth). In addition, one of two RNs (Employee E) did not carry out her responsibilities to ensure that staff under her charge, being one of eleven Certified Nursing Aides (Employee A), was performing her duties, instead of sleeping. The facility staffed to the level necessary to meet the needs of residents, but, facility staffing was compromised by the actions of staff who failed to carry out their responsibilities to provide continuous oversight of residents. Findings include: 1. On 5/3/2012 at approximately 3:00 a.m. the second floor 200 unit was observed with two staff members (nurses) seated at the nurse station. One of those nurses, (employee B) who is a Licensed Practical Nurse, was observed seated in a chair behind the nurse station with her back to the phone and doorbell/monitor system. Further, employee B was observed with her head lying on books that were on the desk and had a blanket over her back to her head. Employee B was visibly sleeping at the time of the observation. During this observation, it was determined Employee B. could not provide care, services and supervision as she was sleeping. During this 11-7 shift, it was determined that employee B, through review of the staffing assignment board, and the detail census report, was responsible for the supervision of two Certified Nursing Assistants and responsible for the care, services and supervision of thirteen residents (# 1 through #13). Of those thirteen residents, twelve were identified as " special care needs " per the resident census and condition form (CMS Form 672) that was completed and signed by the Director of Nursing. During the tour of the 200 unit, no odors or unmet care needs were identified. 2. On 5/3/2012 at approximately 3:00 a.m. the fourth floor 400 unit was observed. One nurse (employee C), who is a Licensed Practical Nurse, was observed seated in a chair behind the nurse station with her head on the table and with a blanket over her back. Employee C was visibly sleeping and did not wake up after this surveyor started asking questions to the other nurse at the station. Employee C could not provide care, services and supervision as she was sleeping at the time of the observation. During this 11-7 shift, through review of the staffing assignment board, and detail census report, it was determined that Employee C was responsible for the supervision of two Certified Nursing Assistants and responsible for the care, services and supervision of twenty-six residents (#27 through #52). Of those twenty-six residents, twenty-six were identified as " special care needs " per the resident census and condition form (CMS Form 672) that was completed and signed by the Director of Nursing. During the tour of the unit, at this time, no odors or unmet care needs were identified. 3. On 5/3/2012 at approximately 3:00 a.m. the fourth floor 400 unit dining room/activity room was observed with the main lights off and with the television on. Further observations revealed pillows and blankets on several of the chairs and on the couch. It was further observed when looking into this room, employee A was in a chair with a blanket and pillow sleeping. The employee overheard other staff talking while the surveyor entered the dining room. She then awoke and got up and left the dining room. When the employee was asked her name and why she was sleeping, she only gave her name and didn't answer as to why she was sleeping and not working. Review of the staffing/assignment board determined that employee A was assigned and responsible for thirteen residents (#14 through #26). It was determined as a result from employee A sleeping, she could not provide care and services to these residents on this 11-7 shift, who were also identified to have " special needs. " Further review of the staffing/assignment board revealed employee D who is the 11-7 nurse supervisor and Registered Nurse on the fourth floor 400 unit was responsible for two Licensed Practical Nurses including (employee C) and four Certified Nursing Assistants including (employee A) The nurse supervisor (employee D) did not ensure the nurse (employee C) and the Certified Nursing Assistant (employee A) were awake and working, which ultimately affected twenty-six " special care needs " residents on the floor. 4. It was determined that, along with employees A (C.N.A.) and C (L.P.N) both sleeping, the nurse supervisor, employee E, who is a Registered Nurse, was not following her job description of supervision of the nurse and aide who were both sleeping, and by that, not ensuring a total of thirty-nine residents on this unit (Fourth floor) were adequately monitored, supervised for direct care and special care needs services. According to the 7 pm - 7 am for 5/2-5/3/2012 "C.N.A. Assignment" sheet, Employee E was assigned two C.N.A.s who covered Rooms 401A through through 421B. Of those, Employee A (C.N.A.) was assigned Rooms 410-421. 5. Review of the facility 672, completed on 5/3/2012, as well as the 5/3/2012, "Detail Census Report-Part 2 Listing by Room" for residents on "Hall 200" and the assignment sheet of that date, detailed the resident special care needs as follows for those assigned to Employee B: 1. Resident # 1 had special care needs of injections, respiratory treatment, treatment for [REDACTED]. 2. Resident # 2 had a special care need of respiratory treatment. 3. Resident # 3 had a special care need of suctioning as needed. 4. Resident # 5 had a special care needs of respiratory treatment and management of pain. 5. Resident # 6 had special care needs of respiratory treatment and pressure sores. 6. Resident # 7 had special care needs of incontinence of bowel and bladder, injections, and pain management. 7. Resident #8 had a special care need of catheter care. 8. Resident # 9 had special care needs of incontinence of bowel and bladder, respiratory treatment, injections, and pain management. 9. Resident # 10 had a care need of bowel incontinence and injections. 10. Resident # 11 had care needs of bowel and bladder incontinence. 11. Resident # 12 had tube feeding as a special care need. 12. Resident # 13 had a special care need of pain management. 13. Resident # 4 had a care need of supervision. B. Review of the facility 672, completed on 5/3/2012, as well as the 5/3/2012, "Detail Census Report-Part 2 Listing by Room" for residents on "Hall 400" and the assignment sheet of that date, detailed the resident special care needs as follows for those assigned to Employees C (L.P.N.) and A(C.N.A.): 14. Resident # 14 had special care needs of catheter care and pressure sores. 15. Resident # 15 had special care needs of incontinence of bowel and bladder. 16. Resident # 16 had special care needs of incontinence of bowel, management of pain, and injections. 17. Resident # 17 had special care needs of catheter care, incontinence of bowel, pressure sores, and pain management. 18. Resident # 18 had special care needs of incontinence of bowel and bladder, and respiratory treatment. 19. Resident # 19 had special care needs of incontinence of bowel and respiratory treatment. 20. Resident # 20 had a special care need of tube feeding and supervision. 21. Resident # 21 had a special care need of pain management. 22. Resident # 22 had special care needs of incontinence of bowel and pain management. 23. Resident # 23 had special care needs of incontinence of bladder and injections. 24. Resident # 24 had special care needs of incontinence of bowel, pain management, and respiratory therapy. 25. Resident # 25 had special care needs of catheter care, incontinence of bladder and bowel, pain management, injections, and respiratory therapy. 26. Resident # 26 had care needs of incontinence of bowel and bladder and supervision. 27. Resident # 27 had care needs of incontinence of bowel and bladder and supervision. 28. Resident # 28 had care needs of incontinence of bowel, injections, and supervision. 29. Resident # 29 had care needs of end of life treatment and has incontinent of bowel. 30. Resident # 30 had care needs of incontinence of bladder, management of pain, and is bedfast. 31. Resident # 31 had care needs of incontinence of bowel and bladder, pain management, injections, and respiratory treatment. 32. Resident # 32 had care needs of incontinence of bowel and bladder, injections and is bedfast. 33. Resident # 33 had care needs of incontinence of bowel and bladder and pain management. 34. Resident # 34 had care needs of catheter care, incontinence of bowel, and tube feeding. 35. Resident # 35 had care needs of respiratory treatment. 36. Resident # 36 had care needs of injections. 37. Resident # 37 had care needs of incontinence of bowel, pain management, and injections. 38. Resident # 38 had incontinence of bowel and bladder and needed supervision. 39. Resident # 39 had care needs of incontinence of bowel and supervision. 40. Resident # 40 had care needs of incontinence of bowel and bladder, tube feeding, and injections. 41. Resident # 41 had care needs of incontinence of bowel and bladder, pain management, injections, [MEDICAL TREATMENT], and supervision. 42. Resident # 42 had care needs of incontinence of bowel and bladder and supervision. 43. Resident # 43 had care needs of incontinence of bowel, respiratory treatment, and supervision. 44. Resident # 44 had care needs of urinary incontinence and supervision. 45. Resident # 45 had care needs of incontinence of bowel and bladder and supervision. 46. Resident # 46 had care needs of urinary incontinence and supervision. 47. Resident # 47 had care needs of incontinence of bowel and bladder and supervision. 48. Resident # 48 had care needs of incontinence of bladder and supervision. 49. Resident # 49 had care needs of incontinence of bladder and bowel and injections. 50. Resident # 50 had care needs of incontinence of bladder and supervision. 51. Resident # 51 had care needs of incontinence of bladder, pressure sores, tube feeding, injections, and respiratory treatment. 52. Resident # 52 had care needs of injections and tube feeding. 6. Review of the facility event log for the date of 5/3/2012 found no references to events which occurred on the 11pm-7am shift for 5/2-5/3/2012. 7. Review of the Licensed Practical Nurse (LPN) job description revealed summary of position: "assumes responsibility and accountability for assigned residents/patients for a shift of duty to ensure that the highest degree of quality care is maintained at all times", and "manages the environment to maintain resident/patient safety and supervise the resident/patient care activity performance by nursing assistants". The essential duties and responsibilities for the Licensed Practical Nurse delineated in the position description revealed to: "Conduct frequent rounds to monitor residents/patient conditions and ensure nursing personnel are performing their work assignments in accordance with acceptable nursing standards". It was evident through observations, employees B and C who were both sleeping, were not performing their duties as per the job description and not supervising their aids who were also sleeping during the work shift. As a result of employees B and C not performing their duties, they were not meeting the needs of care and services, affecting residents on two of three units. 8. Review of the R.N. job description, provided by the facility on 5/18/2012 revealed the following language denoting responsibilities as: Section I. under the supervision of the Director of Nursing, a Registered Nurse supervisor assumes responsibility and accountability for a group of residents/patients for a shift of duty. Section A. Essential Functions of this job description under part b. indicated she directs the work of employees, part h. she enforces facility policies with authority to issue Disciplinary Action Reports as needed, part i. revealed she had Authority to suspend employees for rules violation. Page 2 under part #2 revealed she makes frequent rounds to note resident/patient conditions and to ensure nursing personnel are performing their work assignments in accordance with acceptable nursing standards, part #6 revealed she handles on-call responsibilities as required, part #7 revealed she provides the following functions, section a. is responsible for resident/patient car during his/her respective shift, section m. provides resident/patient care as needed. Page 3 under #14 indicated the nurse will comply with laws and regulations applicable to position and acts in accordance with the company ' s Corporate Compliance Program, #15 will treat all residents, visitors, and staff with courtesy, #20 safety part a. Knows and follows facility rules, part d. Reports and documents any incidents or accidents of residents, staff or visitors to the appropriate facility personnel. #21, Resident Rights under part a. Knows Resident Rights. Help the resident/patient exercise and/protect their rights." 9. Review of the Certified Nursing Aide (CNA) position description revealed under essential duties and responsibilities to: "Follow work assignments, and/or work schedules in completing and performing assigned tasks", "Perform all assigned tasks in accordance with the facility's established policies and procedures, and as instructed by supervisors", "Cooperate with inter-departmental personnel, as well as other facility personnel to ensure that nursing services can be adequately maintained to meet the needs of the residents", and to "Check each resident routinely to ensure that his/her personal care needs are being met in accordance with his/her wishes." 10. The FACILITY EMPLOYEE HANDBOOK (undated), provided on 5/18/2012 by the facility, under "Work Rules and General Information," identified the following standards of conduct on page 25 including: "All employees must: Not violate the rights of residents; ensure residents are treated with dignity; not be negligent in the performance of assigned job duties; not sleep on duty." 11. Interview with the Director of Nursing confirmed staff should not be sleeping during any point while on their shift, including the 11-7 shift, and that the nurse supervisor on the floor is ultimately responsible for the supervision and whereabouts of all her staff on the floor. 12. Interview on 5/18/12 at approximately 1:00 p.m. with the corporate regional vice president for the facility revealed she was called in to take over operational responsibility for the facility on 5/3/12 immediately following the complaint investigation. The clinical team reviewed documentation to determine whether there had been any incidents or adverse events related to the 11:00 p.m. - 7:00 a.m. shift and there was not any noted. On 5/3/12, all staff identified during the complaint survey was suspended pending investigation. On 5/15/12 all of the staff involved in the deficiencies received a written disciplinary action report and were terminated from employment. (Review of the time sheets for the staff members identified in the deficiency statement revealed 5/3/12 was their last day worked). Rounds were made in the facility on 5/3/12 and continue on a daily basis to ensure staff has all supplies necessary to care for the residents and the needs of the residents are being met. Staffing was reviewed by the DON to ensure that there was adequate staff to meet the clinical needs of the residents. The facility has hired an RN weekend supervisor responsible for the entire building on the night shift. The facility is currently interviewing applicants for a RN night shift supervisor position for Monday - Friday. At 8:00 a.m. on 5/4/12 a department head meeting was held to review the pending deficiencies from the complaint survey. It was imperative that all management staff felt the urgency to ensure professional standards were in place while delivering care to the residents. Audit tools were developed and implemented. These audit tools are used on each shift and are on-going as part of the quality assurance program. The regional vice president in coordination with the facility ' s management team developed the following action plan: Immediately upon exit of the surveyors on 5/3/12, in-servicing was initiated. This in-servicing continued on every shift until all regularly scheduled staff members were re-educated. All 101 regularly scheduled staff members had completed the in-service by 5/5/12. The following information was covered in the in-service: A. Building Access: 1. Monitor on 2nd floor must be on and volume on high at all times. No staff is to adjust the volume of the monitor. 2. Phones must be turned over to night shift daily at 8 p.m. by the receptionist. 3. All staff is to answer phones within the 1st 3 rings and respond and let people in the facility timely. B. Dignity: surveyor heard staff curse in front of a resident. 1. All staff must be professional and respectful around residents. 2. No cussing or speaking Spanish is to be done around residents. 3. Spanish should only be used if speaking to a Spanish speaking resident. C. Professional standards: 2 surveyors observed two nurses sleeping, one on the 2nd floor and one the 4th floor, in addition to a C.N.A. and a Nurse Supervisor were not monitoring staff. 1. Termination will be the outcome if a staff member is caught sleeping on the clock! Staff re-educated on the employee handbook as it relates to assigned responsibilities. D. [MEDICAL CONDITION] Care supplies: 1. [MEDICAL CONDITION] bags are to be in the room in the drawer at the bedside. Backup is in the supply room. If you use the last bag in the room you need to replace from the storage room. If you take the last one from the storage room you need to notify the supervisor and document it on the 24 hour report. E. Infection Control: 1. Isolation set ups over the doors must be stocked up at all times and restocked each shift. Personal belongings of staff need to be in lockers not on the units. All staff needs to empty their lockers at the end of the shift for the oncoming shift. The immediate jeopardy was removed and the scope and severity reduced to an "E."