Every finding on record at Windsor Mission Oaks

Based on observations, interviews, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 4 linen carts (LC #1 and LC #2) reviewed for infection control. The facility failed to ensure clean linen was stored properly on the 100 hall. The facility failed to ensure clean linen was stored properly on the 200 hall. These deficient practices could place residents at risk of infection and decline in health.Findings included: 1. During observation and interview on 6/11/26 at 1:03 pm revealed LC #1 on the 100 hall was uncovered. CNA G said linen carts were not supposed to be uncovered because residents could grab stuff and contaminate supplies on the cart. CNA G said all staff were responsible for ensuring linen cart remained covered when not in use. During an interview on 6/11/26 at 1:09 pm, CNA H said she did not deny that she left LC #1 uncovered. CNA H said linen carts were supposed to be covered because they contained clean linen. CNA H said when linen carts were left uncovered the clean linen could be contaminated, causing cross contamination and possible infections. CNA H further stated that CNAs or anybody that knew linen carts should be covered were responsible for ensuring linen carts were covered when not in use. 2. Observation on 6/12/26 at 5:10 am revealed LC #2 on the 200 hall was uncovered. During an interview on 6/12/26 at 5:14 am, CNA I said the linen cart should have been covered so that germs did not get in it, contaminating the clean linen. CNA I further stated that the CNAs were responsible for ensuring linen carts were covered when not in use. During an interview on 6/12/26 at 1:23 pm, the DON said the cover should be on the linen cart or the linen cart should be in the CNA closet. The DON further stated best practice would have been to have the linen carts covered so they were less accessible to the residents because this could cause cross contamination. The DON said the nurses and CNAs were responsible for ensuring the linen carts remained covered. Record review of the facility's policy titled, Infection Prevention and Control Program, dated 5/13/23, revealed: .The facility will establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines.12. Linens: a. Laundry and direct care staff shall handle, store, process, and transport linens to prevent spread of infection.c. Clean linen shall be delivered to resident care units on covered linen carts with covers down. d. Linen shall be stored on all resident care units on covered carts.

Based on observation, interviews and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation.1. The facility failed to label, date, and seal an opened bag of toasted oats cereal and three opened bags of pasta in the dry storage room. 2. The facility failed to store a mop, broom, and multiple mop heads in a sanitary manner in the utility closet.3. The facility failed to store three cases of water bottles off the floor in the storage area outside the kitchen.4. DA P failed to cover all his facial hair with a facial hair restraint while preparing food in the kitchen on 06/29/2025.These failures could place residents who received meals and snacks from the kitchen at risk for food borne illness.The findings included:1. Observation on 06/24/2025 at 9:30 AM in the dry storage room revealed an opened 35-oz. bag of toasted oats cereal on a shelf. The bag was approximately half-full, rolled down, and secured closed with two white labels. There was no marking on the bag indicating the date it was received or a use-by date, and the bag was not in a sealed in a zip-locked bag or sealed container. There were also three 10-lb. bags of pasta (egg noodles, macaroni noodles and tri-color pasta) that had been opened and closed by tying the tops of the bags in knots. The opened bags of pasta were not stored in zip-locked bags or sealed containers.During an interview on 06/24/2025 at 9:34 AM, the FSS stated the bag of cereal should have been labeled with a use-by date and sealed in a zip-locked bag or container and the bags of pasta should have been stored in zip-locked bags or containers. All dietary staff were trained by the DM on labeling, dating, and properly storing opened food upon hire and periodically throughout the year. Failing to store opened food in sealed containers could lead to the proliferation of pests and the potential of contamination with bacteria causing foodborne illness.2. Observation on 06/24/2025 at 9:39 AM in the utility closet revealed a soiled mop and a broom were stored head-side down on the floor inside the closet. There was also one used mop head on the floor and multiple used mop heads on top of a trash bag inside the closet.During an interview on 06/25/2025, the FSS stated the mop and broom should have been stored it in an upright position on the hooks inside the utility closet. The other mop heads should have been sent to laundry for cleaning and sanitizing. 3. Observation on 06/24/2025 at 9:48 AM revealed three cases of 0.5 L bottles of water (24 bottles/case) stacked on top of each other on the floor in the small dry storage area located outside the kitchen.During an interview on 06/24/2025 at 9:49 AM, the FSS stated the water bottles were on the floor of the storage area and should not have been. The facility had received a food delivery that morning, but the bottles of water were not delivered that day and should not have been on the floor. 4. Observation on 06/26/2025 at 9:35 AM in the kitchen revealed DA P stood next to the preparation table and used a spatula to transfer pieces of cake from a pan on the table to a blender on a table near the wall. DA P had a facial hair approximately 1/4 in length on his upper lip that extended the length of his mouth and approximately 1/2 in length that covered his chin and extended to his ears. DA P wore a facial hair restraint that only covered his chin. During an interview on 06/26/2025 at 9:36 AM, DA P stated he knew his facial hair restraint did not cover all his facial hair and should have. He had worked at the facility since 2003 and had been trained to cover his facial hair during food preparation. DA P stated he had just returned from the dish room as a reason his facial hair was not completely covered. He understood it was important to have all facial hair covered by a facial hair restraint to prevent potential cross contamination during food preparation.During an interview on 06/26/2025 at 9:38 AM, the FSS stated DA P's facial hair restraint should have covered all his facial hair and he had been trained upon hire to ensure it did.Record review of the facility's policy 03.003 Food Storage revised 06/01/2019 revealed, Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US Food Codes and HACCP guidelines. Procedure: 1. Dry storage rooms. d. To ensure freshness, store opened and bulk items in tightly covered containers. All containers must be labeled and dated. h. Store all items at least 6 above the floor with adequate clearance between goods and ceiling to protect from overhead pipes and other contamination.Record review of the facility's policy 04.020 Janitor's Closet approved 10/01/2018 revealed, Policy: The facility will maintain the janitor's closet in a sanitary manner to minimize the risk of food hazards. The janitor's closet will be cleaned once per week or more often as needed. 1. Remove contents. Take dirty mop heads and cloths to laundry after each use. 8. Mops and brooms must be stored head up.Record review of the facility's policy 04.001 Employee Sanitation approved 10/01/2018 revealed, Policy: The Nutrition & Foodservice employees of the facility will practice good sanitation practices in accordance with the state and US Food Codes in order to minimize the risk of infection and food borne illness. 3. Employee Cleanliness Requirements. B. Hairnets, headbands, caps, beard coverings or other effective hair restraints must be worn to keep hair from food and food-contact surfaces.Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed, 3-305.11, Food Storage, (A) Food shall be protected from contamination by storing the food: (1) In a clean, dry location; (2) Where it is not exposited to splash, dust, or other contamination; (3) At least 15 cm (6 inches) above the floor. 6-501.16 Drying Mops. After use, mops shall be placed in a position that allows them to air-dry without soiling walls, equipment, or supplies. 2-402. Hair Restraints. 2-402.11 Effectiveness. (A) .Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single service and single-use articles.

Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 2 of 3 residents (Residents #30 and #41) reviewed for incontinent care, in that: 1. The facility failed to ensure CNA I thoroughly cleaned Resident #30 while providing incontinent care. 2. The facility failed to ensure CNA N used the right technique to clean Resident #41 while providing incontinent care. This deficient practice could place residents at-risk for infection and skin break down due to improper care practices. The findings were: 1. Record review of Resident #30's face sheet, dated 06/26/2025, revealed an admission date of 05/01/2012, and a readmission date of 04/23/2022 with diagnoses which included: Type 2 diabetes mellitus (high level of sugar in the blood), Chronic obstructive pulmonary disease (progressive lung disease characterized by airflow limitation), Hypertension (High blood pressure), Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood), Bipolar disorder (Mental disorder characterized by periods of depression and periods of abnormally elevated mood), Major depressive disorder (mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest or pleasure), Osteoporosis (Condition causing bones to become fragile and brittle). Record review of Resident #30's Quarterly MDS assessment, dated 06/16/2025, revealed Resident #30 has a BIMS score of 12, which indicated moderate cognitive impairment. Further review revealed Resident #30 required extensive assistance with ADLs and was indicated to frequently be incontinent of bladder and occasionally incontinent of bowel. Record review of Resident #30's care plan, dated 09/08/2020, revealed a problem of The resident has functional bladder incontinence r/t Confusion, with a goal of The resident will remain free from skin breakdown due to incontinence and brief use through the review date. Observation on 06/26/2025 at 1:10 p.m. revealed, while providing incontinent care for Resident #30, CNA I did not clean the buttocks and hips areas of the resident. During an interview on 06/26/2025 at 1:20 p.m. CNA I stated she did not clean the resident's buttocks' cheeks area or the hips area. CNA I stated she should have cleaned the buttocks and hips areas. CNA I stated she was nervous. CNA I stated she received training for infection control and incontinent care within the last year. During an interview with ADON C on 06/27/2024 at 2:05 p.m., ADON C stated the buttocks and hips areas had to be cleaned. The ADON stated the regional trainer was the one training the staff for infection control and incontinent care and that the ADONs and the regional trainer would check the staff skills annually and as needed if a problem was noted. Review of the Facility's policy, titled Perineal care, dated 10/24/2022. revealed Cleanse buttocks and anus, front to back. 2. Record review of Resident #41's face sheet, dated 06/26/2025, revealed an admission date of 01/10/2014, and a readmission date of 10/31/2024 with diagnoses which included: Type 2 diabetes mellitus (high level of sugar in the blood), Hypertension High blood pressure), Dementia (decline in cognitive abilities), Chronic prostatitis (Inflammation of the prostate gland causing painful urination), Major depressive disorder (mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest or pleasure), Schizophrenia (mental disorder characterized by abnormal thought processes and an unstable mood). Record review of Resident #41's Quarterly MDS assessment, dated 06/09/2025, revealed Resident #41 has a BIMS score of 14, which indicated mild cognitive impairment. Further review revealed Resident #41 required extensive assistance with ADLs and was indicated to have an indwelling catheter and was always incontinent of bowel. Record review of Resident #41's care plan, dated 10/10/2018, revealed a problem of The resident has bowel incontinence r/t Dementia AEB confusion At risk for skin breakdown, with a goal of The resident will have no skin breakdown r/t incontinence through the review date. Observation on 06/26/2025 at 1:49 p.m. revealed, while providing incontinent care for Resident #41, CNA N used a back to front motion, from buttocks to scrotum, to clean the resident buttocks and scrotum area . During an interview on 06/26/2025 at 2:00 p.m. CNA N stated she used a back to front motion to clean Resident #41 and she should have used a front to back motion. She stated she was nervous. CNA N stated she received training for infection control and incontinent care within the last year. During an interview with ADON C on 06/27/2024 at 2:05 p.m., ADON C stated the staff should always use a front to back motion to clean residents to prevent the risk of cross contamination and infection for the residents. Review of the Facility's policy, titled Perineal care, dated 10/24/2022. revealed Cleanse buttocks and anus, front to back. Review of Peri-care: What Every Caregiver Needs to Know By mmLearn.org on Fri, Jun 14, 2019 revealed Moving from front to back, use warm water and a clean washcloth (or disposable wipes) to clean the perineal area. For females, this involves cleaning the inner legs, labia, and groin area while for men it requires cleaning the tip and shaft of the penis, along with the scrotum. Both men and women require cleaning of the anal area, which will involve turning the patient on his/her side.

Based on observations, interviews and record reviews the facility failed to ensure that CNAs were able to demonstrate competency in skills and techniques necessary to care for residents' needs for 2 of 3 residents (Residents #30 and #41 ) by 2 of 8 CNAs (CNA I and CNA N) reviewed for competent staff, in that: 1. The facility failed to ensure CNA I thoroughly cleaned Resident #30 while providing incontinent care. 2. The facility failed to ensure CNA N used the right technique to clean Resident #41 while providing incontinent care. This deficient practice could place residents at-risk for infection and skin break down due to improper care practices. The findings were: 1. Record review of Resident #30's face sheet, dated 06/26/2025, revealed an admission date of 05/01/2012, and a readmission date of 04/23/2022 with diagnoses which included: Type 2 diabetes mellitus (high level of sugar in the blood), Chronic obstructive pulmonary disease (progressive lung disease characterized by airflow limitation), Hypertension (High blood pressure), Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood), Bipolar disorder (Mental disorder characterized by periods of depression and periods of abnormally elevated mood), Major depressive disorder (mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest or pleasure), Osteoporosis (Condition causing bones to become fragile and brittle). Record review of Resident #30's Quarterly MDS assessment, dated 06/16/2025, revealed Resident #30 has a BIMS score of 12, which indicated mild to moderate cognitive impairment. Further review revealed Resident #30 required extensive assistance with ADLs and was indicated to frequently be incontinent of bladder and occasionally incontinent of bowel. Record review of Resident #30's care plan, dated 09/08/2020, revealed a problem of The resident has functional bladder incontinence r/t Confusion, with a goal of The resident will remain free from skin breakdown due to incontinence and brief use through the review date. Observation on 06/26/2025 at 1:10 p.m. revealed, while providing incontinent care for Resident #30, CNA I did not clean the buttocks and hips areas of the resident. During an interview on 06/26/2025 at 1:20 p.m. CNA I stated she did not clean the resident's buttocks' cheeks area or the hips area. CNA I stated she should have cleaned the buttocks and hips areas. CNA I stated she was nervous. CNA I stated she received training for infection control and incontinent care within the last year. During an interview with ADON C on 06/27/2024 at 2:05 p.m., ADON C stated the buttocks and hips areas had to be cleaned. The ADON stated the regional trainer was the one training the staff for infection control and incontinent care and that the ADONs and the regional trainer would check the staff skills annually and as needed if a problem was noted. Review of Facility's competency check for CNA I, dated 9/13/2024, revealed CNA I passed competency for infection control and incontinent care. Review of the Facility's policy, titled Perineal care, dated 10/24/2022. revealed Cleanse buttocks and anus, front to back. Review of Peri-care: What Every Caregiver Needs to Know By mmLearn.org on Fri, Jun 14, 2019 revealed Moving from front to back, use warm water and a clean washcloth (or disposable wipes) to clean the perineal area. For females, this involves cleaning the inner legs, labia, and groin area while for men it requires cleaning the tip and shaft of the penis, along with the scrotum. Both men and women require cleaning of the anal area, which will involve turning the patient on his/her side. 2. Record review of Resident #41's face sheet, dated 06/26/2025, revealed an admission date of 01/10/2014, and a readmission date of 10/31/2024 with diagnoses which included: Type 2 diabetes mellitus (high level of sugar in the blood), Hypertension High blood pressure), Dementia (decline in cognitive abilities), Chronic prostatitis (Inflammation of the prostate gland causing painful urination), Major depressive disorder (mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest or pleasure), Schizophrenia (mental disorder characterized by abnormal thought processes and an unstable mood). Record review of Resident #41's Quarterly MDS assessment, dated 06/09/2025, revealed Resident #41 has a BIMS score of 14, which indicated mild cognitive impairment. Further review revealed Resident #41 required extensive assistance with ADLs and was indicated to have an indwelling catheter and was always incontinent of bowel. Record review of Resident #41's care plan, dated 10/10/2018, revealed a problem of The resident has bowel incontinence r/t Dementia AEB confusion At risk for skin breakdown, with a goal of The resident will have no skin breakdown r/t incontinence through the review date. Observation on 06/26/2025 at 1:49 p.m. revealed, while providing incontinent care for Resident #41, CNA N used a back to front motion, from buttocks to scrotum, to clean the resident buttocks and scrotum area . During an interview on 06/26/2025 at 2:00 p.m. CNA N stated she used a back to front motion to clean Resident #41 and she should have used a front to back motion. She stated she was nervous. CNA N stated she received training for infection control and incontinent care within the last year. During an interview with ADON C on 06/27/2024 at 2:05 p.m., ADON C stated the staff should always use a front to back motion to clean residents to prevent the risk of cross contamination and infection for the residents. The ADON stated the regional trainer was the one training the staff for infection control and incontinent care and that the ADONs and the regional trainer would check the staff skills annually and as needed if a problem was noted. Review of Facility's competency check for CNA N, dated 07/06/2024, revealed CNA N passed competency for infection control and incontinent care. Review of the Facility's policy, titled Perineal care, dated 10/24/2022. revealed Cleanse buttocks and anus, front to back. Review of Peri-care: What Every Caregiver Needs to Know By mmLearn.org on Fri, Jun 14, 2019 revealed Moving from front to back, use warm water and a clean washcloth (or disposable wipes) to clean the perineal area. For females, this involves cleaning the inner legs, labia, and groin area while for men it requires cleaning the tip and shaft of the penis, along with the scrotum. Both men and women require cleaning of the anal area, which will involve turning the patient on his/her side.

Based on observations, interviews, and record reviews the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls, for 1 of 3 nurse medication carts (Hall 500 medication cart) reviewed for security and supervision and for one of one medication room reviewed for safe storage of medications requiring refrigeration. 1. The facility failed to ensure that LVN-R did not leave out a vial of insulin on top of the medication cart and leave that medication cart unlocked and out of line of sight when she went inside Resident #15's room to administer his medication.2. The facility failed to store medications within recommended temperature range in the medication refrigerator in the medication storage room.These deficient practices could place residents at risk of medication misuse or drug diversion and of not receiving therapeutic affect from their medications.The findings included:Observation on 06/26/2025 at 4:26 p.m., revealed LVN-R prepared Resident #15's insulin, drawing up 2 units of Novolin R into a syringe, and then entered Resident #15's room to administer his insulin. LVN-R left the vial of Novolin R unsecured on top of the medication cart and the medication cart unlocked when she went in the room to administer the insulin. During an interview with LVN-R on 06/26/2025 at 4:36 p.m., LVN-R stated she should not have left the insulin vial unsecured on top of the medication cart and the medication cart unlocked when she went into Resident #15's room, as this could have resulted in another resident walking by and taking the insulin, or even getting into the medication cart.Interview on 06/26/2025 at 7:00 p.m. with ADON-C revealed she had already been informed of the incident by LVN-R, and stated LVN-R should not have left the insulin out unsecured, nor left the medication cart unlocked when she went into the resident's room, as this could have resulted in another resident taking the medication. The ADON stated that LVN-R had received training on medication administration, including keeping medications secure and locked.2. During an inspection of the medication refrigerator in the only medication room in the facility on 06/25/2025 at 8:47 a.m. with ADON-C, the temperature of the refrigerator was noted to be at 29 degrees Fahrenheit (F), and re-check 2 minutes later revealed a temperature of 30 degrees F. Inventory of medications stored in the refrigerator included:-22 vials of various insulin vials-8 Trulicity pens-9 containers of various eye drops including Latanoprost and Atropine-27 vials of Lorazepam (anti-anxiety medication)-1 container of Ciproflaxacin (antibiotic)- 4 vials of Perseris/Risperdal (anti-psychotic)-6 vials of Cogentin -2 suppositories of Bisocdyl-5 suppositories of APAP (Tylenol)Record review of the temperature log for medication refrigerator for the month of June 2025 revealed there were 17 of 25 daily entries which recorded a temperature below freezing (32 degrees F). There was no acceptable temperature range listed on the temperature log.During an interview with ADON-C on 06/25/2025 at 8:47 a.m. while inspecting the medication refrigerator revealed ADON-C was initially unable to state the recommended temperature range medications were supposed to be stored at and review of the June 2025 temperature log with ADON-C revealed that there was no temperature range listed on the refrigerator temperature log to provide guidance to the nurses checking the temperature when variances from that temperature should be reported and addressed. ADON-C stated that the temperature range should be on the refrigerator temperature log and she would ensure that it was added to the log and the Nurse's would be inserviced as to correct temperature and what to do if temperature out of range. During an interview on 06/26/2025 at 9:55 am. the Regional Nurse stated that medications stored in the refrigerator should not be stored at below freezing temperature, as this could affect the effectiveness and usability of the medications. She stated the pharmacist checked the medication storage monthly. Record review of the U.S. Food and Drug Administration Guidelines at https://www.fds.gov, current as of 09/19/2017 revealed that according to the product labels from all three U.S. insulin manufacturers, it was recommended that insulin be stored in a refrigerator at approximately 36-46 degree F.Record review of the facility policy titled Medication Carts and Supplies for Administering Meds dated 10/01/2019 revealed Do not leave the medication cart unlocked or unattended in the resident care area. The section of the policy titled Supplies revealed a temperature log with acceptable temperature ranges for each area should be maintained at all times

Based on observation, interviews, and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 3 of 6 residents (Residents #23, #41 and, #46)) reviewed for infection control, in that: 1. While providing transfer assistance for Resident #23, CNA H failed to use proper infection control. 2. While providing catheter care for Resident #41, CNA N and CNA M failed to use proper infection control. 3. While providing incontinent care for Resident #46, CNA K failed to use use proper infection control. These deficient practices could place residents at-risk for infection due to improper care practices. These findings included: 1. Record review of Resident #23's face sheet, dated 06/26/2025, revealed an admission date of 05/07/2025, with diagnoses which included: Dementia (decline in cognitive abilities), Hypothyroidism (under active thyroid), Bipolar disorder (Mental disorder characterized by periods of depression and periods of abnormally elevated mood), Parkinson's disease (movement disorder of the nervous system that worsens over time), Hypertension (High blood pressure), Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood). Record review of Resident #23's MDS Quarterly assessment, dated 05/22/2025, revealed the resident had a BIMS score of 15, indicating no cognitive impairment. Resident #23 required extensive assistance with his activities of daily living and was always incontinent of bowel and bladder. Record review of Resident #23's care plan revealed a care plan initiated 05/07/2025 with a problem of The resident has an ADL self-care performance deficit r/t Dementia, Limited Mobility, Limited ROM, Stroke., and an intervention of TRANSFER: The resident requires Extensive assist and at times Mechanical Lift with 2 staff assistance for transfers. Observation on 06/26/25 at 12:58 p.m., revealed while providing transfer assistance for Resident #23, CNA H touched the bedroom's door to close it with her bare hands. CNA H did not sanitize or wash her hands before putting her gloves on, then, started to provide care for Resident #23. During an interview on 06/26/2025 at 1:05 p.m., CNA H stated the bedroom's door was considered dirty and she should sanitized her hands prior to putting gloves on and starting care. CNA H confirmed receiving training on infection control within the year. During an interview on 06/27/2025 at 2:05 p.m., ADON C stated the staff should have sanitize or wash their hands before putting gloves on and prior to start providing care for the resident. She stated it could cause a risk of cross contamination and infection for the resident. She revealed they provided training on infection control at least once a year and as needed. She revealed they checked the skills of the staff annually and as needed with the assistance of her ADONS and the Regional Trainer. Review of facility policy, titled Handwashing/Hand Hygiene, dated January 2018, revealed Perform hand hygiene before applying non-sterile gloves. 2. Record review of Resident #41's face sheet, dated 06/26/2025, revealed an admission date of 01/10/2014, and a readmission date of 10/31/2024 with diagnoses which included: Type 2 diabetes mellitus (high level of sugar in the blood), Hypertension High blood pressure), Dementia (decline in cognitive abilities), Chronic prostatitis (Inflammation of the prostate gland causing painful urination), Major depressive disorder (mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest or pleasure), Schizophrenia (mental disorder characterized by abnormal thought processes and an unstable mood). Record review of Resident #41's Quarterly MDS assessment, dated 06/09/2025, revealed Resident #41 had a BIMS score of 14, which indicated mild cognitive impairment. Further review revealed Resident #41 required extensive assistance with ADLs and was indicated to have an indwelling catheter and be always incontinent of bowel. Record review of Resident #41's care plan, dated 10/10/2018, revealed a problem of The resident has bowel incontinence r/t Dementia AEB confusion At risk for skin breakdown, with a goal of The resident will have no skin breakdown r/t incontinence through the review date. Observation on 06/26/25 at 1:49 p.m., revealed while providing catheter care for Resident #41, the catheter strap bag fell on the floor, CNA M picked it from the floor and placed it on the side table. CNA M, later used the catheter strap on the resident. CNA M touched the bed and bed remote with her gloved hands and started providing care without changing her gloves. CNA M changed her gloves after cleaning the resident buttocks but did not sanitize her hands before putting clean gloves on. CNA N touched the gown on herself she was going to use during care before washing her hands ( the resident was on EBP). During an interview on 06/26/2025 at 2:00 p.m., CNA N stated she should have not touched the gown before washing her hands. CNA M stated the environment around the resident was considered dirty. CNA M confirmed she should not have picked the catheter strap from the floor and should have changed gloves and sanitized her hands before proving care after touching the bed and bed remote. CNA M stated she should have sanitized her hands between change of gloves. CNA N and CNA M confirmed receiving training on infection control within the year. During an interview on 06/27/2025 at 2:05 p.m., ADON C stated the staff should have sanitized or washed their hands before putting gloves on and prior to start providing care for the resident. She stated supply that had fallen to the floor should not be picked up and used. She stated it could cause a risk of cross contamination and infection for the resident. She revealed they provided training on infection control at least once a year and as needed. She revealed they checked the skills of the staff annually and as needed with the assistance of her ADONS and the Regional Trainer. Review of the Facility's policy, titled Handwashing - Hand Hygiene, dated January 2018, revealed Use an alcohol-based rub [ .] After contact with blood or bodily fluids, after handling used dressing, contaminated equipment, etc, after contact with objects in the immediate vicinity of the resident, after removing gloves 3. Record review of Resident #46's face sheet, dated 06/26/2025, revealed an admission date of 08/29/2024, and a readmission date of 02/15/2025 with diagnoses which included: Schizoaffective disorder (mental disorder characterized by abnormal thought processes and an unstable mood), Vascular dementia (decline in cognitive abilities due to reduce blood flow in the brain), Type 2 diabetes mellitus (high level of sugar in the blood), Hypertension (High blood pressure), Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood), Meniere's disease (chronic inner ear disease resulting in dizziness and problem hearing). Record review of Resident #46's Quarterly MDS assessment, dated 06/02/2025, revealed Resident #46 has a BIMS score of 12, which indicated moderate cognitive impairment. Further review revealed Resident #46 required extensive assistance with ADLs and was indicated to be frequently incontinent of bladder and be always incontinent of bowel. Record review of Resident #46's care plan, dated 09/10/2024, revealed a problem of The resident has FUNCTIONAL, MIXED bladder incontinence r/t Dementia, Impaired Mobility, with a goal of The resident's risk for septicemia (blood infection) will be minimized/prevented via prompt recognition and treatment of symptoms of UTI through the review date. Observation on 06/26/25 at 1:23 p.m., revealed while providing incontinent care for Resident #46, CNA K touched the privacy curtain to close it, with her bare hands. Then without sanitizing her hands and putting gloves on, she touched the clean supplies. CNA K touched the bed remote and the bed with her gloved hands. Without changing gloves and sanitizing her hands, she touched the cleaning wipes and started providing care for Resident #46. During an interview on 06/26/2025 at 1:30 p.m., CNA K stated the environment around the resident was considered dirty. CNA K confirmed she should have changed gloves and sanitized her hands before providing care after touching the bed and bed remote. She stated she was nervous and forgot. CNA K confirmed receiving training on infection control within the year. During an interview on 06/27/2025 at 2:05 p.m., ADON C stated the staff should have sanitized or washed their hands before putting gloves on and prior to start providing care for the resident. She stated it could cause a risk of cross contamination and infection for the resident. She revealed they provided training on infection control at least once a year and as needed. She revealed they checked the skills of the staff annually and as needed with the assistance of her ADONS and the Regional Trainer. Review of the Facility's policy, titled Handwashing - Hand Hygiene, dated January 2018, revealed Use an alcohol-based rub [ .] After contact with blood or bodily fluids, after handling used dressing, contaminated equipment, etc, after contact with objects in the immediate vicinity of the resident, after removing gloves

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents for 4 of 5 units (unit 100, 200, 300, and 400) observed for environment, in that: 1. The facility failed to ensure furniture was in a good state of repair in resident rooms. 2. The facility failed to secure chemical cleaners. 3. The facility failed to ensure outside doors were in a good state of repair. These deficient practices could place residents at risk of a diminished quality of life due to an unsafe environment.The findings included:1. Review of Resident #98's face sheet dated 06/26/2025, revealed an admission date of 11/09/2022 with diagnostics which included: Schizoaffective disorder (mental disorder characterized by abnormal thought processes and an unstable mood), Epilepsy (Seizures), Hypertension (High blood pressure), Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood), Hemiplegia (Paralysis of one side of the body), Intellectual disability, Difficulty in walking.Review of Resident #98's Quarterly MDS assessment dated [DATE], revealed Resident #98 had a BIMS score of 13, indicating mild to moderate cognitive impairment. Resident #98 was ambulatory and required limited to extensive assistance with his activity of daily living. Review of Resident #98's care plan dated 03/13/2023 revealed a problem of The resident is Low risk for falls r/t impaired balance, gait' and a goal of The resident will not sustain serious injury through the review date.Observation on 06/26/25 at 11:30 a.m.during colostomy care for Resident # 98 provided by LVN F, revealed the footboard of the bed was not properly affixed to the bed and was moveable. The surveyor pushed on the right side of the footboard and the left side came up and off the end of the bed. The resident was observed ambulating out of his room with a shuffle and leaning on one side. During an interview on 06/26/2025 at 11:36 a.m. with Resident #98, he revealed he did not think he ever put his hand on the footboard when he was walking by the bed. (the foot board of the bed is by the door of the room).During an interview on 06/26/2025 at 11:37a.m. with the LVN F, she stated the footboard was moveable and was a risk for fall and injury if the resident was using it for support. She revealed any repair needs could be communicated to the maintenance supervision using the TELLS system on their laptop. She was not able to say for how long the footboard had been a concern. During an interview on 06/27/25 at 02:05 p.m. with the Administrator, he stated broken furniture was a risk for accident and injury and broken furniture should be immediately repaired or replaced. He was not aware Resident #98's bed was broken. There was no policy about repair and maintenance of furniture and equipment. 2. Observation at 06/24/2025 at 10:06 a.m. of the housekeeping supply closet on 100 unit revealed the closet was unlocked and contained four, one-gallon containers of cleaning agents including: odor neutralizer, detergent disinfectant, glass and surface cleaner, and tub and tile cleaner. The detergent disinfectant was labeled Danger Keep out of Reach of Children Call Poison Control if Swallowed. Further observation revealed the electronic lock on the supply closet door appeared inoperable. During an interview with Housekeeper A on 06/24/2025 at 10:07 a.m., Housekeeper a confirmed the supply closet was unlocked and should not have been since it contained chemical cleaners that were potentially unsafe for residents to handle. Housekeeper A stated she did not know that the lock was inoperable and that she would have reported it to the Maintenance Director via the TELS communication system if she had known. Observation on 06/24/2025 at 10:56 a.m. revealed the Maintenance Director repairing the lock on the housekeeping supply closet. During an interview with the Maintenance Director on 06/24/2025 at 10:56 a.m., the Maintenance Director stated the electronic lock on the supply closet door utilized batteries which had become oxidized, causing the lock to become inoperable. The Maintenance Director stated he did not know how long the lock had been inoperable and confirmed he was in the process of repairing it. During an interview with ADON C on 06/26/2025 at 3:42 p.m., ADON C stated the facility had no policy regarding Physical Environment. During an interview with the Administrator on 06/26/2025 at 4:00 p.m., the Administrator confirmed the facility had no policy regarding Physical Environment and stated his expectation was that cleaning agents with warning labels be kept secure and away from residents. 3. Observation and interview with the Maintenance Director on 06/26/2025 at 10:55 a.m. revealed the Maintenance Director confirmed there were spaces underneath the doors leading to the patio at the end of both 300 and 400 units. The Maintenance Director stated the spaces measured ½ inch and that the issue had not before been brought to his attention. The Maintenance Director stated it was possible for flies to enter the facility via the spaces under the doors and for air conditioning to exit. During an interview with ADON C on 06/26/2025 at 3:42 p.m., ADON C stated the facility had no policy regarding Physical Environment. During an interview with the Administrator on 06/26/2025 at 4:00 p.m., the Administrator confirmed the facility had no policy regarding Physical Environment and stated his expectation was that the facility structures be kept in good repair.

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program for 3 of 5 units (unit 100, 300, and 400) reviewed for effective pest control in that: Numerous flies were observed throughout the investigation period in and around units 100, 300, and 400. This deficient practice could result in diminished quality of life for residents die to living in an environment with pests. The findings were: Observations on 06/24/2025 between 10:10 a.m. and 11:30 a.m. revealed numerous flies in the hallway and in resident rooms on the 400 unit. Observation on 06/24/2025 at 11:49 a.m., during the lunchtime meal service, revealed numerous flies in the 100 unit dining room. Observation on 06/24/2025 at 11:55 a.m., during the lunchtime meal service, revealed numerous of flies in the dining room between units 300 and 400. During an interview with CNA B on 06/24/2025 at 11:56 a.m., CNA B confirmed there were numerous flies during the lunchtime meal service in the dining room between units 300 and 400. During a confidential interview with members of the Resident Council on 06/26/2025 at 10:30 a.m., the Resident Council stated flies were present throughout the facility and were very bothersome. Resident Council members stated they had observed flies in their rooms and in dining areas. Record review of the facility contracts revealed a contract, undated, for pest control service was in place. Record review of the pest control visit logs dated 02/01/2025 through 06/02/2025, revealed the pest control service visited the facility once per month. During an interview with ADON C on 06/26/2025 at 3:42 p.m., ADON C stated the facility had no policy regarding Pest Control. During an interview with the Administrator on 06/26/2025 at 4:00 p.m., the Administrator confirmed the facility had no policy regarding pest control. The Administrator stated that the pest control program had been ineffective regarding flies, and he planned to contact the pest control company and look for unorthodox solutions and was committed to keep trying until the pest control program was effective.

Based on interview and record review the facility failed to ensure the resident had the right to be informed in advance of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options, and to choose the alternative or option he preferred for 1 of 3 Residents (Resident #91) whose records were reviewed for informed consent. The facility failed to ensure psychoactive medication consents for Resident #91's were signed and dated by his Guardian for the use of Zyprexa (antipsychotic medication), Haldol (antipsychotic medication), Perseris (atypical antipsychotic), Zoloft (anti-depressant) and Trazodone (anti-depressant). This failure could place residents at risk for receiving psychoactive medications without consent and knowledge of side effects. The findings were: Record review of Resident #91's admission Record dated 6/27/2025 revealed a [AGE] year-old-man admitted [DATE] and re-admitted on [DATE] with diagnoses which included: Schizoaffective Disorder (a mental health condition including schizophrenia and mood disorder symptoms); Anxiety Disorder (condition with intense, excessive, and persistent worry and fear about everyday situations) and Major Depressive Disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities). Further review revealed Resident #91 had a legal guardian. Record review of Resident #91's annual MDS assessment dated [DATE] revealed he had a BIMS score of 14 indicating intact cognition and was taking anti-psychotic, anti-anxiety, and anti-depressant medications. Record review of Resident #91's Order Summary dated 6/27/2025 revealed orders which included: - Haloperidol Lactate Oral Concentrate 2mg/ml - Give 2 ml by mouth two times a day related to Schizoaffective Disorder, Bipolar Type. - Perseris Prefilled Syringe 120mg (Risperidone ER). Inject 120 mg subcutaneously one time a day starting on the last day of month and ending on the last day of month every month related Schizoaffective Disorder, Bipolar Type. - Trazodone HCL Oral Tablet 150mg. Give 1 tablet by mouth at bedtime for insomnia. - Zoloft Oral Tablet 50 mg (Sertraline HCL) Give 1 tablet by mouth one time a day related Schizoaffective Disorder, Bipolar Type; Anxiety Disorder. - Zyprexa Zydis Oral Tablet Disintegrating 15mg (Olanzapine) Give 1 tablet by mouth at bedtime related Schizoaffective Disorder, Bipolar Type. Record review of Resident #91's Care Plan initiated 04/05/2021 revealed problem areas which included: -use of antipsychotic medications (Zyprexa, Perseris, Haldol) r/t Schizoaffective disorder bipolar type; -use of anti-anxiety medications (Ativan) r/t Anxiety disorder; -use of antidepressant medication (Trazodone, Zoloft) r/t insomnia, depression. Interventions on these problem areas of the Care Plan included intervention to Educate the resident/family/caregivers about risks, benefits and the side effects and/or toxic symptoms of psychotropic medication drugs being given Interview was attempted with Resident #91 on 06/24/2025 at 12:00 p.m. but he was unable to answer any questions about the medications he takes. Record review of Resident #19's Consent for Antipsychotic or Neuroleptic Medication Treatment for Zyprexa, Haldol and Perseris reflected it was signed by the Health Care Professional recommending treatment on 4/15/2021, but the signature of the Legal Guardian was not dated. Record review of Resident #19's Informed Consent for Psychoactive Medications for the medications Zoloft and Trazodone reflected it did not include the dates of the signature of the facility representative providing the information or the date telephone consent was obtained from the Legal Guardian. During an interview on 06/26/2025 at 2:56 p.m., ADON-C stated she was the facility representative who signed the Informed Consent and obtained the telephone consent from Resident #19's Legal Guardian for his Zoloft and Trazodone and confirmed she had not dated her signature or the telephone consent from the Legal Guardian. ADON-C further stated she failed to ensure the signature of the Legal Guardian was dated for his combined consent for the Zyprexa, Haldol and Perseris. ADON-C stated she must have just forgotten to date the signatures on the consents, and stated that it was important to have signatures dated on the consents to show that proper consent was obtained prior to starting the medication or treatment. Record review of the facility policy titled use of Psychotropic medications dated 03/05/2025 revealed: - Prior to initiating or increasing a psychotropic medication, the resident, family, and/or resident representative must be informed of the benefits, risks, and alternatives for the medication, including any black box warnings for antipsychotic medications, in advance of such initiation or increase; and -The facility will document that the resident or resident representative was informed in advance of the risks and benefits of the proposed care, the treatment alternatives or other options and the preferred option to accept or decline in a format the facility deems to use (e.g., written consent form, narrative note, etc.). .

Based on interviews and record reviews, the facility failed to ensure a comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 1 of 29 residents (Resident #49) reviewed for care plans. 1. The facility failed to revise Resident #49's comprehensive care plan to include a diagnosis of depression.2. The facility failed to revise Resident #49's comprehensive care plan to include the resident's use of a psychotropic medication (Sertraline).These failures could place residents at risk of not receiving appropriate interventions to meet their current health needs.The findings were: 1. Record review of Resident #49's face sheet dated 06/25/2025 revealed the resident was a [AGE] year old male with diagnoses that included: Type II diabetes with hyperglycemia (a chronic condition when the body cannot use insulin correctly and sugar builds up in the blood), fracture of surgical neck of right humerus (a break in the upper arm bone where it connects to the shoulder joint), hypertensive heart disease (heart conditions that develop as result of high blood pressure) and major depressive disorder, single episode (a severe depressive episode lasting at least two weeks marked by persistent sadness, loss of interest in previously enjoyed activities, and significant impairment in daily functioning).Record review of Resident #49's significant change MDS dated [DATE] revealed a BIMS score of 10/15, indicating the resident had moderately impaired cognition. Section I - Active Diagnoses revealed I5800, Depression (other than Bipolar) was checked.Record review of Resident #49's quarterly MDS dated [DATE] revealed a BIMS score of 15/15, indicating the resident had intact cognition. Section I - Active Diagnoses revealed I5800, Depression (other than Bipolar) was checked.Record review of Resident #49's Active Diagnoses List dated 06/26/2025 revealed a diagnosis of Major Depressive Disorder, Single Episode, Unspecified. The date of the diagnosis was 02/07/2025.Record review of Resident #49's comprehensive care plan, revised 06/24/2025, revealed a focus area noting Resident #49 had the potential to be physically aggressive, initiated 03/25/2025. Interventions included administering medications as ordered and psychiatric/psychogeriatric consult as indicated. There was no focus area indicating a diagnosis of depression, goals, or interventions for the diagnosis.2. Record review of Resident #49's Active Orders as of 06/26/2025 revealed an order for: Zoloft Oral Tablet 25 MG (Sertraline HCl) Give 1 tablet by mouth one time a day for depression. Active 02/07/2025, Start Date 02/08/2025. No end date was indicated.Record review of Resident #49's significant change MDS dated [DATE] and quarterly MDS dated [DATE] revealed both indicated in Section N0415. High-Risk Drug Classes: Use and Indication, C., Antidepressant was checked.Record review of Resident #49's comprehensive care plan, revised 06/24/2025, revealed there was no focus area indicating the use of a psychotropic medication, goals, or interventions for this medication.During an interview on 06/27/2025 at 1:05 PM, MDS RN O stated both Resident #49's diagnosis of depression and his use of a psychotropic medication were not noted as focus areas in his updated comprehensive care plan and should have been. He was responsible for updating care plans did not know why the diagnosis and medication were missed, as the resident received two MDS assessments since both the diagnosis was made and the medication was prescribed. He had a system for noting which residents required care plan updates and he simply missed updating Resident #49's care plan. MDS RN O stated it was important for the diagnosis of depression to be in the care plan so staff could monitor for signs and symptoms of depression, such as its potential effect on the resident's nutritional status and his interaction with others, and the for the psychotropic medication to be noted so staff could monitor for potential side effects.During an interview on 06/26/2025 at 1:30 PM, ADON C stated both Resident #49's diagnosis of depression and his order for the psychotropic medication Sertraline should have been noted in his comprehensive care plan, MDS RN O was responsible for updating resident care plans, and she could not explain the omissions in Resident #49's care plan.Record review of facility policy Care Plan Revisions Upon Status Change implemented 10/24/2022 revealed, The purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change. 1. The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change. 2. Procedure for reviewing and revising the care plan when a resident experiences a status change: a. Upon identification of a change in status, the nurse will notify the MDS Coordinator, the physician, and the resident representative, if applicable. b. The MDS Coordinator and the Interdisciplinary Team will discuss the resident condition and collaborate on intervention options. c. The team meeting discussion will be documented in the nursing progress notes. d. The care plan will be updated with the new or modified interventions. e. Staff involved in the care of the resident will report resident response to new or modified interventions. f. Care plans will be modified as needed by the MDS Coordinator or other designated staff member.

Based on observation, interview, and record review the facility failed to ensure that a resident who is fed by enteral means receives the appropriate treatment and services to prevent complications of enteral feeding for 1 of 1 resident (Resident #9 ) reviewed for enteral feeding (method to provide nutrition and fluids directly into digestive tract via a feeding tube): LVN Q failed to flush Resident #9's enteral feeding tube per physician's orders. This deficient practice could place residents who received enteral nutrition and medications at increased risk of aspiration, infection, bloating discomfort, and not receiving the full benefit of the medications administered. The findings included: Record review of Resident #9's admission Record dated 06/26/2025 revealed a [AGE] year-old man admitted on [DATE] with re-admission on [DATE], with diagnoses which included: Cerebral Infarction (stroke); Dysphagia (difficulty swallowing food or liquids); and Gastrostomy Status (a surgical procedure in which a tube is inserted directly into the stomach through the abdominal wall to provide a way to deliver nutrition, fluids, or medications). Record review of Resident #9's admission MDS assessment dated [DATE] revealed the resident was moderately cognitively impaired for daily decision-making skills and utilized an enteral feeding tube. Record review of Resident #9's Order Summary Report dated 06/26/2025 revealed the following Physician Orders: - Enteral Feed Order as needed Complete tube site care q shift. - Enteral Feed Order five times a day Flush with 130ml water before and after each feeding. - Enteral Feed Order five times a day related to APHASIA FOLLOWING CEREBRAL INFARCTION (169.320) Bolus with Two Cal HN 1 carton (237ml) 5x/day via Gtube. Provides 2375 Kcal, 99G protein, 830ml free water, 2130 total ml fluids + water flushes. Record review of Resident #9's comprehensive care plan with initiation date of 05/10/2024 revealed the resident required tube feeding related to Dysphagia, NPO, with interventions which included The resident is dependent with tube feeding and water flushes. See MD order for current feeding orders. Observation on 06/26/2025 at 11:00a.m. of Resident #9's bolus enteral feeding revealed LVN Q administered one-half carton of Two Cal HN formula without flushing Resident #9's G-tube with 130ml of water before administering the formula. LVN Q realized her mistake after pouring half the carton of formula into the syringe, and after the syringe was empty, LVN Q administered the 130ml of water, and then administered the last half of the Two Cal HN formula. During an interview on 06/26/2025 at 11:07 a.m., LVN Q stated she should have flushed Resident #9's g-tube with 130 ml of water prior to administering his bolus feeding of formula, but she was in a hurry and just forgot. She stated she realized her mistake after pouring the first half of his formula and tried to correct by administering the water midway through his bolus feeding. LVN Q stated not flushing the G-tube with water first could result in the G-tube not being cleared, and could cause clogging of the G-tube. During an interview on 06/26/2025 at 3:47 p.m., ADON-C stated LVN-Q should have followed physician orders and flushed the G-tube with the prescribed amount of water before administering Resident #9's formula, and that not flushing first could result in the tube becoming clogged. Record review of facility policy titled Enteral Tube Medication Administration dated 10/01/2019 revealed Check the medication administration record (MAR) to confirm the order: note the medication, dose, route (tube) and volume of water for flushing and Medication administration via tube requires flushing with water at several steps in the procedure .

Based on interviews and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours to the State agency for 2 of 9 residents (Residents #1 and #5) reviewed for failure to report. 1. The facility did not report an allegation of misappropriation of property for Resident #1 to the State Agency. 2. The facility did not report an allegation of misappropriation of property for Resident #5 to the State Agency. This failure could place residents at risk of abuse, neglect, or misappropriation of resident property. Findings included: 1. Record review of the Admission Record for Resident #1 revealed she was a [AGE] year-old female who was originally admitted to the facility on [DATE] with diagnoses which included: schizoaffective disorder (a chronic mental illness involving symptoms of schizophrenia and characterized by symptoms such as delusions and hallucinations), and multiple fractures of the pelvis. Record review of Resident #1's Quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 14, indicating no cognitive impairment. Record review of a facility complaint/grievance report form, dated 03/29/2024, stated the nature of the complaint was, Resident #1 stated someone stole her cellular device from her room. Documentation of the facility follow-up on the report form dated 03/29/2024, listed the facility Social Worker as the person who was notified, and the Social Worker wrote, Social Services informed Resident #1 she will ask staff and look around the facility for her device. Resolution of the concern/grievance dated 04/01/2024 and completed by the facility Social Worker read, Social Services informed Resident #1 that she was not able to find/locate her phone. Social Services will contact phone company to see if phone can be replaced through Social Security. Update: Social Services verified that all residents are only allowed one phone per year. Further review revealed the report form was signed by the facility Social Worker and by the facility Administrator on 04/10/2024. During an interview with Resident #1 on 05/22/2024 at 10:40 a.m., the resident stated she believed someone stole her phone. Resident #1 stated she had received the phone from the facility Social Worker a few days prior to it going missing. The resident stated she had received the phone through a special program and showed the investigator a cellular phone box that included a phone number to the device. The resident stated she had the phone plugged in to the charger on her nightstand to charge it overnight and when she woke up in the morning, the phone was missing. Resident #1 stated she reported the missing phone directly to the facility Social Worker, and the Social Worker looked around her room, and told her she was only allowed one phone per year. During an interview with the Social Worker on 05/22/2024 at 11:30 a.m., the Social Worker stated she was responsible for completing grievance forms when items were reported missing. The Social Worker stated she filled out the form and then gave them to the Administrator to review and sign. When asked how missing items were investigated, the Social Worker stated she looks for the items and asks the staff if they have seen the items in question. When asked about Resident #1's grievance form, dated 03/29/2024, regarding the missing phone, the Social Worker stated she gave Resident #1 the new phone on Monday, 03/25/2024. The Social Worker further stated Resident #1 reported the phone as stolen to her on 03/29/2024. The Social Worker stated Resident #1 had reported the phone was charging on her nightstand overnight and was gone on the morning of 03/29/2024. The Social Worker stated she looked for Resident #1's phone and talked to staff about it. The Social Worker stated she notified the Administrator about Resident #1's missing phone and stated he was the Abuse Prevention Coordinator. The Social Worker further stated the Administrator should have reported the resident's missing phone and was not sure if it was reported by the Administrator to the state agency or the local police department. During an interview with the Administrator on 05/23/2024 at 2:20 p.m., the Administrator stated he was the Abuse Prevention Coordinator, and he was responsible for reporting allegations of abuse, neglect, and misappropriation of residents' property to the state agency. The Administrator stated he was not aware Resident #1's cellular phone had gone missing, and he did not remember being told about the missing phone. When asked if an allegation of a stolen phone should have been reported to the local police department and the state agency the Administrator stated, yes, if it meets the criteria of misappropriation, it should have been investigated and reported. The Administrator was shown a copy of the complaint/grievance reported dated 3/29/2024 regarding Resident's #1 reporting her phone as stolen and he responded, yes, that is my signature on the bottom and yes it should have been reported. When asked why it was important for allegations of abuse and misappropriation to be reported the Administrator stated, it's like the cry wolf theory, how do you know what happened if you do not investigate it. People don't get to pick and choose what is reportable. When asked what harm could happen to a resident if an allegation is not reported the Administrator responded, psychological harm could occur if it is not investigated and reported and they are missing their items. 2. Record review of the Admission Record for Resident #5 revealed she was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included: hypertension (heart problems caused by high blood pressure), and mild neurocognitive disorder (a type of progressive disease associated with abnormal deposits of protein called Lewy bodies in the brain which that leads to decline in thinking, reasoning, and independent function). Record review of Resident #5's Quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 13, indicating no cognitive impairment. Record review of a facility complaint/grievance report form, dated 03/27/2024, stated the nature of the complaint was, Resident #5 stated someone stole her cellular device out of her room and she cannot find her device. Documentation of the facility follow-up on the report form, dated 03/27/2024, listed the person notified as the facility Social Worker and read, Social Services informed Resident #5 that she would look around the facility and ask staff for device (if they noticed where the device could be). The resolution of the concern/grievance, dated 04/01/2024, read, Social Services informed Resident #5 that she will continue looking for the device. Although she is only allowed 1 phone per year through Social Security. Resident #5 stated that she understood. Further review revealed the report form was signed by the Social Worker and by the Administrator on 04/10/2024. During an interview with the Social Worker on 05/22/2024 at 11:22 a.m., the Social Worker stated she had provided Resident #5 with a new cellular phone on 03/25/2024. The Social Worker stated Resident #5 reported to her on 03/27/2024 that her phone was stolen from her room. The Social Worker stated Resident #5 had told her the phone was on her nightstand when it went missing. The Social Worker stated she had no idea what happened to Resident #5's missing phone, and further stated the Administrator was notified of the allegation and signed the concern/grievance form. During an interview with Resident #5 on 05/22/2024 at 1:50 p.m., the resident stated she was provided a cellular phone by the Social Worker and had received the phone only a few days before it went missing. Resident #5 stated she left her phone on her nightstand while she went to lunch in the dining room, and when she returned to her room the phone was gone. The resident stated she reported the missing phone to the Social Worker, and the Social Worker told her, Nothing could be done about it. During an interview with the Administrator on 05/23/2024 at 2:20 p.m., the Administrator stated he did not remember being told Resident #5 reported her cellular phone as stolen. The Administrator did acknowledge signing the complaint/grievance report, dated 03/27/2024, regarding Resident #5's allegation of a stole cellular phone and stated it should have been reported to the local police and the state agency. The Administrator stated he was the Abuse Prevention Coordinator. When asked what harm could happen to a resident if an allegation is not reported the Administrator responded, psychological harm could occur if it is not investigated and reported and they are missing their items. Record review of the facility's policy titled, Abuse, Neglect, and Exploitation, dated 08/15/2022, revealed, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. The facility will have written procedures that include: Reporting of all alleged violations to the Administrator, state agency, adult protective services, and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b). Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.

Based on interviews and record review, the facility failed to thoroughly investigate allegations of misappropriation of resident property for 2 of 9 residents (Residents #1 and #5) reviewed for the investigation of allegations. 1) The facility did not investigate when Residents #1 reported an allegation of misappropriation of property. 2) The facility did not investigate when Residents #5 reported an allegation of misappropriation of property. Findings included: 1. Record review of the Admission Record for Resident #1 revealed she was a [AGE] year-old female who was originally admitted to the facility on [DATE] with diagnoses which included: schizoaffective disorder (a chronic mental illness involving symptoms of schizophrenia and characterized by symptoms such as delusions and hallucinations), and multiple fractures of the pelvis. Record review of Resident #1's quarterly MDS, dated [DATE], revealed the resident has a a BIMS score of 14, indicating no cognitive impairment. Record review of a facility complaint/grievance report form, dated 03/29/2024, stated the nature of the complaint was Resident #1 stated someone stole her cellular device from her room. Documentation of facility follow up on the report form dated 03/29/2024, listed the facility Social Worker as the person who was notified, and the Social Worker wrote, Social Services informed Resident #1 she will ask staff and look around the facility for her device. Resolution of the concern/grievance dated 04/01/2024 and completed by the facility Social Worker stated Social Services informed Resident #1 that she was not able to find/locate her phone. Social Services will contact phone company to see if phone can be replaced through Social Security. Update: Social Services verified that all residents are only allowed one phone per year. The report form is signed by the facility Social Worker and by the facility Administrator on 04/10/2024. During an interview with Resident #1 on 05/22/2024 at 10:40am, she stated that she believed someone stole her phone. Resident #1 said she had received the phone from the facility Social Worker a few days prior to it going missing. The resident stated said she had received the phone through a special program and showed the investigator a cellular phone box that included a phone number to the device. The resident stated she had the phone plugged in to the charger on her nightstand to charge it overnight and when she woke up in the morning, the phone was missing. Resident #1 stated she reported the missing phone directly to the facility Social Worker. and the Social Worker looked around her room and told her she was only allowed one phone per year. During an interview with the facility Social Worker on 05/22/2024 at 11:30am, the Social Worker stated she is responsible for completing grievance forms when items are reported missing. The Social Worker stated she fills out the form and then takes it to the Administrator to review and sign. When asked how missing items are investigated, the Social Worker stated she looks for the items and asks the staff if they have seen the items in question. When asked about Resident #1's grievance form, dated 03/29/2024, regarding the missing phone she stated she gave Resident #1 the new phone on Monday, 03/25/2024. The Social Worker further stated Resident #1 reported the phone as stolen to her on 03/29/2024 and said Resident #1 reported the phone was charging on her nightstand overnight and was gone on the morning of 03/29/2024. She stated she looked for Resident #1's phone in her room and laundry and talked to staff about it. She said she did not remember how many people she asked about it. When asked if she had documentation of an investigation and interviews, she said no. The Social Worker stated she notified the Administrator about it and stated he was the Abuse Prevention Coordinator. The Social Worker stated, he signed the grievance form and said the Administrator should have investigated it and was not sure if it was investigated by the Administrator. During an interview with the Administrator on 05/23/2024 at 2:20pm, the Administrator stated he was the Abuse Prevention Coordinator, and he was responsible for investing and reporting allegations of abuse, neglect, and misappropriation of resident property. He stated he was not aware that Resident #1's cellular phone had gone missing and stated he did not remember being told about the missing phone. When asked if an allegation of a stolen phone should have been investigated, he said yes, if it meets the criteria of misappropriation, it should have been investigated. The Administrator was shown a copy of the complaint/grievance reported dated 3/29/2024 regarding Resident's #1 reporting her phone as stolen and he responded yes, that is my signature on the bottom and yes it should have been investigated. When asked why it is important for allegations of abuse and misappropriation to be reported he stated it's like the cry wolf theory, how do you know what happened if you do not investigate it. People don't get to pick and choose what is reportable. When asked what harm could happen to a resident if an allegation is not reported the Administrator responded, psychological harm could occur if it is not investigated and reported and they are missing their items. 2. Record review of the Admission Record for Resident #5 revealed she was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included: hypertension (heart problems caused by high blood pressure), and mild neurocognitive disorder (a type of progressive disease associated with abnormal deposits of protein called Lewy bodies in the brain which that leads to decline in thinking, reasoning, and independent function). Record review of Resident #5's Quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 13, indicating no cognitive impairment. Record review of a facility complaint/grievance report form, dated 03/27/2024, stated the nature of the complaint was, Resident #5 stated someone stole her cellular device out of her room and she cannot find her device. Documentation of facility follow-up on the report form, dated 03/27/2024, listed the person notified as the facility Social Worker and read, Social Services informed Resident #5 that she would look around the facility and ask staff for device (if they noticed where the device could be). The resolution of the concern/grievance, dated 04/01/2024, read, Social Services informed Resident #5 that she will continue looking for the device. Although she is only allowed 1 phone per year through Social Security. Resident #5 stated that she understood. Further review revealed the report form was signed by the Social Worker and by the Administrator on 04/10/2024. During an interview with the Social Worker on 05/22/2024 at 11:22 a.m., the Social Worker state she had provided Resident #5 with a new cellular phone on 03/25/2024. The Social Worker stated Resident #5 reported to her on 03/27/2024 that her phone was stolen from her room. The Social Worker stated Resident #5 had told her the phone was on her nightstand when it went missing. The Social Worker stated she had no idea what happened to Resident #5's missing phone, and further stated the Administrator was notified of the allegation and signed the concern/grievance form. During an interview with Resident #5 on 05/22/2024 at 1:50 p.m., the resident stated she was provided a cellular phone by the Social Worker and had received the phone only a few days before it went missing. Resident #5 stated she left her phone on her nightstand while she went to lunch in the dining room, and when she returned to her room the phone was gone. The resident stated she reported the missing phone to the Social Worker, and the Social Worker told her, Nothing could be done about it. During an interview with the Administrator on 05/23/2024 at 2:20 p.m., the Administrator stated he did not remember being told Resident #5 reported her cellular phone as stolen. The Administrator did acknowledge signing the complaint/grievance report, dated 03/27/2024, regarding Resident #5's allegation of a stole cellular phone and stated it should have been investigated. The Administrator stated he was the Abuse Prevention Coordinator. Record review of the facility Abuse, Neglect and Exploitation policy dated 08/15/2022 stated as the policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. The policy further stated The facility will have written procedures that include: Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b). Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.

Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision to prevent accidents for 1 of 3 residents (Resident #21) reviewed for accidents and supervision, in that: The facility failed to supervise Resident #21 who eloped from the facility on 05/02/24. An Immediate Jeopardy (IJ) was identified as past non-compliance on 05/07/24. The non-compliance began on 05/02/24 and ended on 05/04/24. The facility had corrected the non-compliance before the survey began on 05/05/24. This deficient practice could place residents who were elopement risks at-risk of harm, serious injury, or death. The findings included: Record review of the face sheet for Resident #21 dated 5/6/24 revealed the 55- year- old male resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: unspecified dementia (a condition of cognitive impairment that can have occur for various reasons), schizoaffective disorder (a condition that affects a person's mood and ability to think and behave clearly), and anxiety disorder (a condition in which there are strong feelings of worry or fear). Record review of Resident #21's Annual MDS dated [DATE] revealed the resident had a BIMS score of a 9 which indicated that the Resident was cognitively impaired. The MDS indicated that the resident exhibited a significant risk of wandering behavior. Record review of the Quarterly care plan for Resident #21 dated 4/10/24 revealed the resident had a risk of elopement potential. The interventions included identifying the pattern of wandering and distracting the resident from wandering with pleasant diversions and structured activities. Further review revealed the resident's care plan was changed on 5/2/24 to include the resident's elopement on 5/2/24. Record review of wandering assessment for Resident #21 dated 7/27/23 noted the resident had a history of wandering and was a risk for wandering behavior to continue. The wandering assessment was revised on 5/2/24 to include the elopement incident. Record review of the physician order summary for Resident #21 dated 5/8/24 revealed the resident was under the care of psychiatric services for medication management and behavior monitoring. Record review of the one-on-one supervision log for Resident #21 dated 05/08/24 revealed the resident was under continuous one-on -one supervision by nursing staff since return to the facility from the elopement with the plan for the on-on-one supervision to be continued. Observation from 05/05/24 to 05/08/24 between the hours of 8:00 a.m. and 4:00 p.m., of all the resident corridor hallways revealed the door alarms were in working order. During an interview with the DON on 5/6/24 at 11:15 a.m. regarding the elopement incident., the DON stated that Resident #21 had eloped from the facility on 5/2/24 during the 4:00 p.m. smoke break. The DON stated that at the initiation time of the smoke breaks the hall corridor doors alarms for the four resident hallways were disengaged by the activity staff to allow the residents to enter the outside smoking area and then re-engaged when the smoke break was over. The DON stated on 5/2/24 Resident #21 had not joined the resident smoking group but instead walked independently around the fence perimeter and proceeded to remove several of the boards from the eight- foot- high fence and scaled the fence to leave the facility property at 4:20 p.m. The DON further stated that upon noticing the fence breakage, the staff began an immediate elopement protocol which included resident head count to determine that Resident #21 was missing along with notification of the local police department, the physician, and the resident's responsible party. The DON stated that multiple facility staff also conducted a grounds and neighborhood hood search for the resident who was located at 5:15 p.m. several blocks away from the facility and was then returned to the facility. The DON stated a complete Head- to- Toe assessment of Resident #21 was completed and revealed no injuries. The DON stated that the resident said he was glad to be back at the facility and had been looking for a soda and a bakery. The DON stated that upon Resident #21's return to the facility, the resident was placed immediately on 24 hour one-on-one supervision. The DON further stated that the practice of the hall corridor alarms being de-activated during the smoke breaks was immediately terminated and all hall corridor door alarms would stay activated at all times. The DON stated that the resident's 24/7 one-on-one supervision would continue until a new fencing structure was put into place on the facility grounds which would restrict all resident access to any outside area which was not in direct visual observation of the staff who were outside with the residents. The DON stated that he and the ADON staff routinely did outside perimeter rounds of the facility ground several times a day. During an interview with the Administrator on 5/6/24 at 1:45 p.m., the Administrator stated that he had ordered that all resident corridor doors keep their door alarms engaged at all times. The Administrator further stated that he had approved the construction of a 10- foot tall fence on the outside grounds of the facility which would restrict resident access to only being under the direct visual observation of the staff at all times. During an interview with the Regional [NAME] President for Operations on 5/6/24 at 1:50 p.m., the Regional [NAME] President for Operations stated that he had authorized the financial payment for the facility's fence construction to prevent resident elopement. During an interview with the Maintenance Director on 5/6/24 at 3:00 p.m., the Maintenance Director stated that he completed regular inspections of the outside fence area surrounding the facility for structural integrity. The Maintenance Director further stated that the resident hallway door alarm codes were changed on a monthly basis. The Administrator was notified on 5/7/24 at 4:00 p.m., that a past non-compliance IJ situation had been identified due to the above failure. It was determined the failures placed Resident #21 in an IJ situation on 5/7/24. The facility implemented the following interventions. During an interview with CNAs M and N on 5/6/24 from 3:10 p.m. to 3:20 p.m., CNAs M and N stated they completed three outside perimeter checks of the facility perimeter during their 2:00 p.m. to 10:00 p.m. shift assignments. During an interviews on 5/6/24 at from 4:15 p.m. to 4:54 p.m. the Housekeeping Supervisor, 8 CNAs (P, Q, R,S, T, U, V and X), NA W, 4 LVNs (Y, AA, DD And BB), 2 RNs (The DON and Z ), Activity Aide CC who stated they had received the facility in-service on elopement conducted from 5/2/24 -5/4/24 and which included: information on a-routine resident 2 hour checks, awareness of the elopement binder, and monitoring residents for exit seeking behaviors such as checking exits, pushing on doors, and verbalizing wanting to leave the facility. The Housekeeping Supervisor stated that the staff work as a team to prevent resident elopements which included 3 facility perimeter checks during the 2-10:00 p.m. shift. During an interview on 5/7/24 from 8:00 a.m. to 8:34 a.m. with 10 CNAs (EE, C, FF, GG, HH, II, JJ, D, E, KK) 7LVNs (LL, MM, ADON A, ADON B, OO, QQ, and G) RN PP at 8:00 a.m., who confirmed she had received the facility in-service on elopement conducted from 5/2/24 -5/4/24 and which included: information on a-routine resident 2 hour checks, awareness of the elopement binder, and monitoring residents for exit seeking behaviors such as checking exits, pushing on doors, and verbalizing wanting to leave the facility. The CNA EE stated that the staff work as a team to prevent resident elopements which included facility perimeter checks during the 2:00 p.m.-10:00 p.m. shift. Record review of the fence construction estimate at the facility, dated 5/7/24 revealed the estimate was approved. Record review of the facility's policy titled, Elopements and Wandering Residents, dated 11/21/22, revealed, the facility is to ensure that residents who exhibit wandering behavior and are at risk for elopement receive adequate supervision to prevent accidents and receive care related to their elopement risk.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that: 1. Cook A was did not wear a facial hair restraint while engaged in food preparation and service. 2. There were ten thermometers in the hand-washing sink. 3. In the reach-in cooler there was a 5-lb. bag of Mozzarella cheese past its use-by date and containers of thickened juice and milk without labels indicating a use-by date. 4. Cook B wore a wristwatch on his arm while preparing food in the kitchen. 5. The chemical sanitizing solution in the dish machine did not reach the minimum ppm required. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: 1. Observation on [DATE] at 11:20 AM in the kitchen revealed Cook A stood in the the kitchen, covered plates of food that were assembled by dietary aides, and placed the trays on carts. Cook A had hair approximately ,d+[DATE] in length that covered his upper lip and the chin portion of his face. Cook A was not wearing a facial hair restraint. During an interview on [DATE] at 11:21 AM with the Cook he stated he knew he should have worn a facial hair restraint, he wore prior to using the restroom and failed to put it back on upon his return to the kitchen. During an interview on [DATE] at 11:22 AM with the FSS she stated Cook A had facial hair, was not wearing a facial hair restraint, and knew he should be wearing one. 2. Observation on on [DATE] at 11:23 AM. in the kitchen revealed a two-compartment sink. A sign on the wall above the sink read, Handwashing Sink. In the right compartment there were ten bimetallic stemmed thermometers routinely used to measure food temperatures. The indicator head of one thermometer was inside the drain portion of the sink. During an interview on [DATE] at 11:24 AM with the FSS she confirmed the two-compartment sink was the kitchen's handwashing sink, and indicated the single compartment sink along the left wall was the food preparation sink. The FSS stated the thermometers should not have been in the handwashing sink. 3. Observation on [DATE] at 11:28 a.m. revealed a 5 lb. bag of shredded Mozzarella cheese. The bag was half-full and stored inside a sealed, zipper-locked bag. In the section on the storage bag labeled, Date, [DATE] was written in black marker. In the section labeled Use By, [DATE] was written in black marker. Further observation in the reach-in cooler revealed: A 46-oz. container of thickened orange juice. The container was half-full and did not have a label indicating the date it was opened and a use-by date, and a one-gallon container of whole milk that was half-full and did not have a label indicating the date it was opened and a use-by date. During an interview on [DATE] at 1:15 PM with the FSS she stated the Mozzarella cheese was past its use-by date and should have been discarded, and the thickened juice and milk should have been labeled with use-by dates. It was the responsibility of the cooks and dietary aides to properly label and date food items stored in the coolers and freezers. Staff were trained upon hire and monthly by her and the consultant dietitian. 4. Observation on [DATE] at 11:31 AM in the kitchen revealed Cook B mashed potatoes in a pan and scooped stuffing into another pan. Cook B wore a wristwatch on his left wrist. During an interview on [DATE] at 11:32 AM with Cook B he stated he knew he should not have won a watch during food preparation and forgot to take it off. During an interview on [DATE] at 1:15 PM with the FSS she stated dietary staff were prohibited from wearing jewelry on their hands during food preparation and were trained during orientation. 5. Observation on [DATE] at 11:35 AM in the dish room revealed Cook B operated the dish machine. Upon the conclusion of the cycle, Cook B dipped a chlorine test strip in the sanitizer solution, waited a few seconds, and compared the color change against the chart provided on the container. Observation of the color of the test strip revealed it closely resembled the color associated with 10 ppm (parts per million). Cook B ran the dish machine again and upon conclusion of the cycle another test strip was used. This test strip also indicated the concentration of chlorine in the sanitation solution was 10 ppm. During an interview on [DATE] at 11:35 AM Cook B stated the concentration of chlorine was inadequate and he would contact the service provider of the machine. During an interview on [DATE] at 11:09 AM with the FSS she stated the reason the test strips used on [DATE] indicated the concentration of chlorine in the machine was below the minimum required level of 50 ppm was because the strips were expired, and she had since procured a new container of test strips. Observation on [DATE] at 11:15 AM in the dish room revealed the FSS ran the dish machine, a test strip was used from the new container, and the color of the test strip indicated the level of chlorine in the sanitizer solution was in the 10 ppm range. Record review of facility policy 04.001 Employee Sanitation approved [DATE] revealed, 3. Employee Cleanliness Requirements: b. Hairnets, headbands, caps, beard coverings or other effective hair restraints must be worn to keep hair from food and food-contact surfaces. f. No jewelry can be worn on the arms and hands while preparing food except for a single plain ring such as a wedding band. Record review of facility policy 04.002 Hand Washing approved [DATE] revealed, Procedure: 1. Hand-washing Stations. d. Sinks used for food preparation or washing utensils or a service sink .cannot be used as a hand-washing station. Review of facility policy 04.006, Food Storage, Revised [DATE], revealed, Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US Food Codes and HACCP guidelines. 2. Refrigerators d. Date, label and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage. e. Use all leftovers within 72 hours. Discard items that are over 72 hours old. Record review of facility policy 04.006 Mechanical Cleaning and Sanitizing of Utensils and Portable Equipment approved [DATE] revealed, Policy: The facility will follow the cleaning and sanitizing requirements of the state and US Food Codes for mechanical cleaning in order to ensure that all utensils and equipment are thoroughly cleaned and sanitized to minimize the risk of food hazards. 2. Make sure that the automatic detergent dispenser and/or liquid sanitizer injector is working properly. 7. If a machine that uses f. A test kit or other device that accurately measures the parts per million concentrations of the solution must be available and used. A sample Dish Machine Temperature and Sanitizing Log follows this policy. Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, ,d+[DATE].11, revealed, (A) Except as provided in (B) of this section, Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single service and single-use articles. Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, ,d+[DATE].15, revealed, Where to Wash. Food employees shall clean their hands in a handwashing sink or approved automatic handwashing facility and may not clean their hands in a sink used for food preparation or warewashing, or in a service sink or a curbed cleaning facility used for the disposal of mop water and similar liquid waste. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed ,d+[DATE].17 Ready-to-Eat/Time Temperature Control for Safety Food, Date Marking. (B) Except as specified in (E) -(G) of this section, refrigerated, ready-to-eat, time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety. Review of product storage instructions from the manufacturer of the thickened orange juice, water and sweet tea revealed all three products had the same storage instructions: Refrigerate after opening and use within 7 days. https://lyonsreadycare.com/collections/dysphagia/products/thickened-orange-juice-cartons-nectar-level-2. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2012, U.S. Department of H&HS, revealed, ,d+[DATE].11 Jewelry Prohibition. Except for a plain ring such as a wedding band, while preparing food, food employees may not wear jewelry including medical information jewelry on their arms and hands. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed: ,d+[DATE].114 Manual and Mechanical Warewashing Equipment, Chemical Sanitization -Temperature, pH, Concentration, and Hardness. A chemical sanitizer used in a sanitizing solution for a manual or mechanical operation at contact times specified under ,d+[DATE].11(C) shall meet the criteria specified under S,d+[DATE].11 Sanitizers, Criteria, shall be used in accordance with the EPA-registered label use instructions, and shall be used as follows: (A) A chlorine solution shall have a minimum temperature based on the concentration and PH of the solution as listed in the following chart: Concentration Minimum Minimum Range Temperature Temperature mg/L pH 10 or Less pH 8 or Less ,d+[DATE] 120 degrees F 120 degrees F ,d+[DATE] 100 degrees F 75 degrees F

Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals were secured properly for 3 of 3 residents (Residents #43, #79, and #91) reviewed for medications, in that: LVN LL pre-poured medications for Residents #43, #79, and #91 and stored them in the top drawer of the medication cart. These deficient practices could place residents at risk of not receiving the intended therapeutic benefit of their medications as ordered. The findings were: 1. Record review of Resident #43's face sheet, dated 5/5/24, revealed a [AGE] year-old male admitted to the facility on [DATE] with the diagnosis that included Dementia (a general term for loss of memory, language, problem-solving, and other thinking abilities), hypertension (when your blood pressure, the force of blood flowing through your blood vessels, is consistently too high), and Schizoaffective disorder (mental health disorder that is marked by symptoms, such as hallucinations). Record review of Resident #43's Quarterly MDS, dated [DATE], revealed a BIMS score of 9, which indicated cognition was moderately impaired. Record review of the Residents #43's Physician monthly order summary for May 2024 revealed, that the following medications were ordered at 9:00 a.m. For Resident #43, Invega for 24 hours, administer one three-mg tab once a day orally for schizoaffective disorder; Losartan 50 mg, administer one tablet orally once a day orally for hypertension; Lyrica, 25 mg capsule, administer one capsule three times a day for pain, Metformin 850 mg tablet administer one tablet once day orally for diabetes Mellitus and Provera 10 mg tab administer three tablets once a day = 30 mg total for inappropriate behaviors. 2. Record review of Resident #79's face sheet, dated 5/5/24, revealed a [AGE] year old -female [AGE] year-old admitted on [DATE] with the diagnosis that included Paranoid schizophrenia (psychosis, which means your mind does not agree with reality), diabetes mellitus (a disease with inadequate control of blood sugar glucose), and Epilepsy (a brain disorder that causes recurring, unprovoked seizures). Record review of Residents #79's Quarterly MDS dated [DATE], revealed the resident had a BIMS of 9, which indicated cognition was moderately impaired. Record review of Residents #79 Physician monthly orders for May 2024 revealed the following medications were ordered at 9:00 a.m., for Resident #79, Gabapentin 300 mg capsule three times a day for polyneuropathy, Valbenazine tosylate tablet administer one tab once a day for tardive dyskinesia, and levetiracetam 500 mg once day seizures. 3. Record review of Resident #91's face sheet, dated 5/5/24, revealed a [AGE] year-old male admitted on [DATE] with the diagnosis that included Schizophrenia (involves delusions, hallucinations, unusual physical behavior, and disorganized thinking and speech), Diabetes Mellitus (a disease in which the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine), and overactive bladder (muscles of the bladder start to tighten on their own even when the amount of urine). Record review of Resident #91's Quarterly MDS dated [DATE], revealed a BIMS score of 15, which indicated cognition is intake. Record review of Resident's #91 Physician orders for May 2024 revealed that the following medications were ordered at 9:00 a.m. for Resident #91, Lasix 20 mg administer one tablet by mouth daily for fluid retention. Gabapentin 300 mg, administer one capsule three times a day by mouth for polyneuropathy; Valbenazine tosylate administer one tablet by mouth daily for tardive dyskinesia; and levetiracetam 500 mg, administer one tablet once a day for seizures. Observation and interview with LVN LL on 5/5/54 at 10:30 a.m. revealed medications for Residents #43, #79, and #91 were in the top drawer of the medication cart. LVN LL stated she had written names on medication cups that medications were in and had signed out medication administration record as she had pre-pulled medications for Resident #43, #79 and #91. LVN LL stated medications were not to be poured and signed out as residents may need to be sent out to the hospital and medication administration record may not be accurate. In an interview with the DON on 5/4/24 at 10:45 a.m., the DON stated LVN LL should not have pre-pulled medications for Residents #43, #79, and #91 and stored them on top of the medical cart drawer. The DON stated this deficient practice could lead to medication administration records reflecting incorrect documentation if Residents #43, #79, and #91 were to be sent to the hospital. The DON stated the ADONs monitored nurses at random during the week for storing pre-poured medications in medication carts, and he was overseeing this. Record review of the facility's policy titled, Monitoring of Medication Administration, dated 10/1/19, revealed that medication administration, including frequency, is documented.

Based on observation, interview and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 4 of 5 resident hallways reviewed for environmental conditions ensure in that: The facility failed to ensure four resident hallways did not have hallway side rails that were not clean and sticky to the physical touch. This deficient practice could place residents at risk of living in an unsanitary environment. The findings included: Observation on 5/5/24 from 10:15a.m.,to 10:40 a.m., on the resident 500 hallway revealed that the hallway side rails on both sides of the hallway appeared to be unclean with a noticeable sticky touch to the side rails. The motion of leaning up against the siderails caused the Surveyor-L's pants to stick to the side rail in multiple locations on the hallway. Observation on 5/8/24 from 1:00pm to 1:20 pm with the Housekeeping Director revealed the following: a-the side rail outside of room [ROOM NUMBER] appeared unclean with a sticky touch to the surface. b-the side rails on both sides of resident hallway 200 appeared unclean with a sticky touch to the surface. c-the side rail outside of room [ROOM NUMBER] appeared unclean with a sticky touch to the surface. During an interview with the Housekeeping Director on 5/8/24 at 1:25 p.m., he stated that housekeepers were assigned to regularly clean the resident hallways and would wipe off an identified sticky portion of the siderail when it was reported to them. The Housekeeping Director stated that he completed daily monitoring of the housekeepers cleaning assignments. During an interview on 5/8/24 at 1:45 p.m., the Administrator stated that he felt the facility resident hall handrails were cleaned all the time. The Administrator stated that having clean resident hall handrails was important for the cleanliness of the facility. Record review of the facility's Environmental Services Policies and Procedures Manual that was undated stated that the facility provides sufficient housekeeping and maintenance personnel, equipment, and supplies to maintain the interior and exterior of the facility in a safe, clean, orderly, and attractive manner.

Based on observation, record review, and interview the facility failed to have an ongoing and effective pest control program for 1 of 1 building reviewed for pest control. The facility did not have an effective pest control program to eradicate the flies in the facility. The facility failure placed residents at risk for diarrhea, dysentery (infectious diarrhea), salmonella (an infection that can lead to diarrhea, fever, and stomach cramps), and other serious health concerns. Findings included: Observation on 05/05/2024 at 10:57 a.m. revealed one fly landed on a laptop while on hall 300 Observation on 05/05/2024 at 11:14 a.m. revealed a fly landing on a person on 400 hall. Record review of Resident #33's face sheet, dated 05/08/2024, revealed an admitted [DATE] and, a readmitted [DATE] with diagnoses which included: Dementia (decline in cognitive abilities), Hemiplegia(Paralysis of one side of the body), Type 2 diabetes mellitus (high level of sugar in the blood), Hypertension (High blood pressure) and, Chronic kidney disease (gradual loss of kidney function). Record review of Resident #33's Quarterly MDS assessment, dated 03/20/2024, revealed a BIMS score of 99 with memory problem and modified independence. Observation on 05/07/2024 at 11:00 a.m., during administration of Insulin to Resident #33, revealed there were 3 flies were noted on the bed of Resident #33. In an interview with Resident #33 on 05/07/2024 at 11:02 a.m., Resident #33 revealed the flies were his friends that carry messages for him. In an interview with LVN G on 05/07/2024 at 11:05 a.m., LVN G stated the facility had flies and they probably entered when people went in and out of the facility from smoking. In an interview with LVN H on 05/07/24 at 11:10 a.m., LVN H confirmed there were flies in the facility. LVN H stated the number of flies used to be worse but they were still around. LVN H stated she thought the flies entered by the back door and there were nothing on top of the door to keep them from entering. Observation on 05/07/2024 at 11:25 a.m., during lunch service, revealed a couple of flies were seen around residents when they were eating. No resident verbally complained about them when asked but they were swatting at them Observation on 05/08/2024 at 9:10 a.m. revealed there were flies in the social worker office. The Social Worker did not comment on the presence of the flies. Observation on 05/07/2024 at 2:00 p.m. revealed there were flies in the dishwashing room and in the sink area of the kitchen. Record review of contracts revealed the facility had a contract with a professional company for pest control, and they were contracted to come monthly and as needed if called Record Review of the sighting log revealed on 4/16/2024 and 04/29/2024 flies were sighted in the facility. Record review of service log form revealed the pest control company did a visit on 4/29/2024 but treated the facility for fire ants not flies. Further review of the log revealed the pest control company treated for flies on 4/4/2024. During an interview on 05/08/2024 at 10:50 a.m., the Administrator confirmed the presence of flies in the facility. The Administrator state the facility's plan was to increase the number of visit from the pest control company and to treat for flies every time. The Administrator confirmed the pest control company was coming monthly and also as needed if the staff was reporting pest in the sighting log.

Based on interview and record review, the facility failed to ensure the staff members were educated on the rights of the resident and the responsibilities of the facility to properly care for its residents for 4 of 22 staff (CNA N, the Food Service Director, the Physical Therapist, and the Speech Therapist) reviewed for training requirements in that: The facility failed to ensure four staff which included: CNA N, the Food Service Director, the Physical Therapist, and the Speech Therapist received the required training on resident rights during the year 2023. This deficient practice could place residents at risk of receiving care from staff who were insufficiently trained. The findings included: Record review of the undated facility staff list revealed that CNA N was hired on 7/8/93, the Food Service Director was hired on 8/10/2005, the Physical Therapist was hired on 2/16/2015, and the Speech Therapist was hired on 2/1/2012. During an interview with the Director of Human Resources on 5/7/2024 at 1:00 p.m. she stated that there was not documentation that CNA N, the Food Service Director, the Physical Therapist, or the Speech Therapist received Resident Rights training in 2023. The Director of Human Resources stated she felt the Department Heads, the Human Resources Director, the Administrator, and the employee themselves were all responsible for ensuring the required education was completed. The Human Resources Director stated completion of the Resident Rights training would help the staff to be better educated when providing resident care. The Human Resources Director stated that the facility did not have a policy on the need for employees to complete their required in-service training. During an interview with the Administrator on 5/7/2024 at 4:00 p.m., the Administratir stated employees needed to complete their required training. The Administrator stated completing their required in-service training would help their overall provision of resident care.

Based on interview and record review, the facility failed to ensure the staff members were educated on abuse, neglect, and exploitation related to resident care for 5 (CNA F, the Food Service Director, LVN G, the Occupational Therapist, and the Speech Therapist) of 22 staff reviewed for training requirements in that: The facility failed to ensure that five staff which included: CNA F, the Food Service Director, LVN G, the Occupational Therapist, and the Speech Therapist received the required training on abuse/neglect/exploitation during the year 2023. This deficient practice could place residents at risk of receiving care from staff who were insufficiently trained. The findings included: Record review of the undated facility staff list revealed that CNA F was hired on 4/19/2019, the Food Service Director was hired on 8/10/05, LVN G was hired on 7/14/08, the Occupation Therapist was hired on 4/3/23, and the Speech Therapist was hired on 2/1/2012. During an interview with the Director of Human Resources on 5/7/2024 at 1:00 p.m. she stated that there was not documentation that CNA UU, the Food Service Director, LVN TT, the Occupational Therapist, or the Speech Therapist received Abuse/Neglect/Exploitation training in 2023. She stated she felt the Department Heads, the Human Resources Director, the Administrator, and the employee themselves were all responsible for ensuring the required education was completed. The Human Resources Director stated completion of the abuse/neglect/exploitation training would help the staff to be better educated when providing resident care. The Human Resources Director stated that the facility did not have a policy on the need for employees to complete their required in-service training. During an interview with the Administrator on 5/7/2024 at 4:00 p.m., he stated that employees needed to complete their required in-service training. The Administrator stated that completing their required in-service training would help their overall provision of resident care.

Based on observation, interview, and record review the facility failed to ensure the residents right to be free from abuse for 1 of 4 residents (Resident #1) reviewed for abuse, in that; The facility failed to ensure Resident #1, who was on a pureed diet, was provided the correct diet and supervision when Resident was fed and consumed a regular diet on [DATE] which resulted in a choking event, loss of consciousness requiring the [MEDICATION(S)] maneuver, back thrusts, and CPR before being revived and receiving treatment at the hospital. This failure resulted in identification of Immediate Jeopardy (IJ) on [DATE] at 8:25 p.m. While the immediacy was removed on [DATE], the facility remained out of compliance at actual harm that was not immediate jeopardy with a scope of isolated due to the facility's need to monitor the implementation and effectiveness of its POR. This deficient practice could affect residents with physician ordered mechanically altered diets and result in aspiration, pneumonia, choking and/or death from being fed food not appropriate for their diet. The findings were: Record review of Resident #1's face sheet, dated [DATE] revealed a [AGE] year-old male admitted on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's annual MDS dated [DATE] revealed the resident had a BIMs score of 7 which indicated a severe cognitive impairment. A review of Resident #1's functional status revealed he required limited assistance of one staff person with physical assistance with eating. Record review of Resident #1 Visit Notes dated [DATE] and signed by the Behavioral Therapist revealed: The Behavioral Therapist documented Resident #1 was anxious and suspicious, his thought process was intact, and his impulse control presents as poor. Treatment plan goal: Follow dietary guidelines consistently. Record review of Resident #1's Care Plan dated [DATE] and last revised [DATE] revealed Resident #1 The resident has little or no activity involvement .he has been going outside and trying to grab snacks from the snack trays and drinks. Has to be redirected cause [sic] he is a pureed and thickener [sic] He has been redirected several times getting food from the carts (meal carts). He has been redirected not [to] eat the regular food due to his diet texture with interventions which included The resident needs assistance/escort to activity functions. Record review of Resident #1 Care Plan dated [DATE] and last revised on [DATE] revealed Resident #1 had an ADL self-care performance deficit related to confusion with interventions which included for eating: The resident requires supervision, tray set up, verbal cues and at times guidance assistance by 1 staff to eat. A review of Resident #1's swallowing/nutritional status revealed the MDS was marked that he did not have any signs or symptoms of a possible swallowing disorder. Record review of Resident #1's Care Plan dated [DATE] and last revised [DATE] revealed Resident #1 was resistive to care related to Alzheimer's dementia and was non-compliant with ordered diet . grabs food off carts and other resident trays and gets verbally aggressive and demanding with redirection with interventions which included: Allow Resident #1 to make decisions about treatment regime, to provide sense of control, educate Resident #1 of possible outcomes of not complying with treatment or care . Record review of Resident #1's Care Plan dated [DATE] and last revised on [DATE] revealed Resident #1 had impaired cognitive function/dementia or impaired thought process related to Alzheimer's dementia .with interventions which included: cue, reorient and supervise as needed. Record review of Resident #1's Care Plan dated [DATE] revealed Resident #1 had [CONDITION(S)] disease with interventions which included: diet as ordered, monitor/document/report to MD as needed signs and symptoms of aspiration or dysphagia: choking, fever, coughing. Refer to Speech Therapist for any dysphagia problems. Record review of Resident #1's Care Plan dated [DATE], last revised on [DATE] revealed: Resident #1 has potential nutritional problems related to Alzheimer's dementia, [CONDITION(S)] .with interventions which included: Explain and reinforce to the resident the importance of maintaining the diet ordered, encourage the resident to comply, explain consequences of refusal, invite the resident to activities that promote additional intake, monitor/document/report as needed any signs and symptoms of dysphagia such as pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat or appearing concerned during meals. Provide and serve a diet as ordered. Record review of Resident #1's Care Plan dated [DATE], last revised on [DATE] revealed: Resident #1 has a swallowing problem with history of coughing or choking during meals .with interventions which included: All staff to be informed of residents special dietary and safety needs, diet to be followed as prescribed, resident to eat only with supervision. Record review of Resident #1's Dietary assessment dated [DATE] revealed: Resident #1 was on a regular diet with pureed texture with honey thickened liquids. Documented under chewing/swallowing difficulty: tolerates current diet well. The assessment notes revealed: diet is desirable and tolerated well .meal intake is greater than 75% and meets estimated needs . Record review of Resident #1's Order Summary Report for [DATE] revealed physician orders for hospice care services with a start date of [DATE]. Record review of Resident #1's Order Summary Report for [DATE] revealed the resident had physician orders with a start date of [DATE] for a regular diet with pureed texture, honey thickened liquids with fortified foods at breakfast. Record review of Resident #1's Order Summary Report for [DATE] revealed there were no physician orders for pleasure feeds, free diet days or any other deviation from a pureed texture diet. Record review of Resident #1's Dietary Nutrition notes dated [DATE] revealed: Resident is on a puree texture with honey thickened liquids. Magic cup in a.m. and p.m., other puree snacks are offered to resident, will continue to monitor per nursing and dietary. Record review of Resident #1's Annual Care Plan review dated [DATE] revealed: Resident is alert with BIM's 6 of 15 indicating a severe cognitive impairment. Resident is on hospice services for [CONDITION(S)] diseases of the nervous system. Resident is a Full Code status. Reviewed meds, diet, activity preferences .and behaviors. Resident is stable, calm, quiet, stays to himself. Record review of Resident #1's nursing progress notes revealed: [DATE]: Resident #1 eats with supervision and needs some assistance when eating meals due to hand tremors [DATE]: Supervision, set-up assistance needed with all meals .asked for a candy bar. [DATE]: Resident continues to be confused. Easily redirectable. [DATE]: Confused, needs constant redirection [DATE] at 1:25 p.m.: Resident consumed 100% of both breakfast and lunch, redirected multiple times due to grabbing food off trays, accepts snacks. [DATE] at 2:33 p.m.: Resident non-compliant with diet. [He] was eating rice and corn, no coughing noted, will continue to monitor. [DATE] at 9:38 p.m.: Resident confused, easily redirected . [DATE] at 3:20 p.m.: Resident #1 non-compliant with his pureed diet and honey thickened fluid consistency. Staff noted [resident] grabbing food during snack time and was physically aggressive on redirection .noted patient appeared anxious and could not clear airway. [MEDICATION(S)] [maneuver] (also known as abdominal thrusts; first aid procedure used to treat remove a foreign object from the airway) performed by nursing staff, noted large pieces of food escaping airway, continued with pallor (pale skin color) and wheezing (high pitched or coarse whistling sound that is heard in the airway caused by an underlying issue such as foreign body obstruction) .called 911 due to abrupt change in respiratory status. Documented by RN D. Record review of Resident #1's Nursing Change of Condition Communication Form dated [DATE] at 3:15 p.m. revealed: Resident #1 had a choking event on [DATE] with abdominal thrust and back blows. The document indicated Resident #1 had new or worsening behavioral symptoms with decreased consciousness, shortness of breath and abnormal lung sounds. Record review of Resident #1's physician orders dated [DATE] at 3:27 p.m. revealed: Resident #1 was sent out 911 EMS to a local hospital for evaluation and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's hospital Emergency Care Note dated [DATE] at 3:39 p.m. at a local hospital revealed: Resident #1 presents to the ER from nursing home via EMS due to choking episode with unresponsiveness. [MEDICATION(S)] performed at nursing home and a small piece of hotdog was removed. When EMS arrived, patient was unresponsive and had shallow respirations. During transport to ER, patient apparently lost pulse and required 1 minute of CPR. [NAME] forceps (special long angled forces used to remove foreign bodies from the airway) were used by EMS and another hotdog piece was removed from mouth. Patient was on nonrebreather (special medical oxygen mask used to help people who can still breathe on their own but need a lot of extra oxygen) with spontaneous respirations upon arrival to ER. Record review of Resident #1's hospital Critical Care Notes dated [DATE] at 6:08 p.m. revealed: Concern for high probability of imminent or life-threatening deterioration. status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Aggressive antibiotics and imaging ordered. Patient had choking episode at nursing home that required [MEDICATION(S)] maneuver, required CPR during transport to ER, arousable to pain, moves extremities to pain, lactic acid markedly elevated (lab test: when elevated it can indicate a decrease in oxygen in the body), concern for aspiration pneumonia (infection that occurs in the lungs after inhalation of a large amount of food, liquid, stomach acid or saliva into the lungs), [CONDITION(S)] protocol started (early aggressive treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Patient became more alert and back to baseline .patient asking to eat in ER. Repeat lactic acid markedly lower. Concern for Aspiration pneumonia so will discharge back to nursing home with [MEDICATION(S)] (antibiotics used to treat infection) . During an observation/interview on [DATE] at 1:03 p.m., Resident #1 was observed consuming a pureed food item while seated at a table alone, with multiple staff nearby. Resident #1 responded to his name but was unable to be understood when he was speaking mumbles sounds. CNA A entered the room during the interview and Resident #1 was asked several questions. CNA A stated she was not able to understand what the resident was saying. During an interview on [DATE] at 1:06 p.m., CNA A stated Resident #1 was difficult to understand. She stated Resident #1 had dementia and could be combative at times because he was easily agitated. CNA A stated resident #1 gets in altercations with other residents in the dining room because he tries to grab other residents' food and must be supervised and seated away from other residents. CNA A stated Resident #1 was on a pureed diet with thickened liquids. She stated Resident #1 would ask for more food even when he has not eaten what is in front of him and always wants bread. CNA A stated Resident #1 did not have a good memory. During an interview on [DATE] at 1:22 p.m. LVN B stated Resident #1 had behaviors which included stealing food from other residents' trays and from the dirty food trays after meals. She stated when he had these behaviors, she redirected Resident #1 and offers him a snack. LVN B stated Resident #1 was easily redirectable and on a modified diet of pureed texture diet with honey thickened liquids. LVN B stated Resident #1 went to the hospital for emergency care because during the facility Easter Celebration on [DATE], Resident #1 who did not chew well, ate a hotdog which lodged in his throat. She stated Resident #1 went to the hospital and when he came back to the facility he was on prophylactic [MEDICATION(S)] for pneumonia. LVN B stated on special occasions such as the Easter Celebration on [DATE] there are doctor orders for all residents to eat whatever they want. During this interview LVN B was not able to produce the physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . LVN B stated Resident #1 had no safety awareness. During an interview on [DATE] at 2:09 p.m. Resident #1's Legal Guardian (RP) stated Resident #1 was on hospice care services but on [DATE] she was notified by an unknown facility staff person Resident #1 was transported to the hospital because he had something lodged in his throat. The RP stated she was later notified he was stable and would return to the facility. She stated she was unaware of what was stuck in Resident #1's throat. She also stated she was unsure what diet Resident #1 was supposed to consume. The RP stated she was very concerned about the resident and had requested a care plan meeting with the facility to discuss. During an interview on [DATE] at 3:47 p.m. LVN E stated on [DATE] during evening shift at a facility celebration held outside of the facility, she was walking around when she saw LVN F doing the [MEDICATION(S)] maneuver in a seated position on the floor on Resident #1. LVN E stated after a couple of minutes the DON took over trying to get what was lodged in Resident #1's throat out. She stated Resident #1 was not breathing properly, so the DON gave the resident back thrusts, and something came out of the resident's mouth. LVN E stated the Resident #1 took a deep breath and started getting color back, started coughing. She stated 911 had already been called. LVN E stated she was not responsible for Resident #1's care at the time, she only wrote the progress note. LVN E stated she did not know what foods were served at the celebration or who was supervising the festivities. She stated I do not know. I cannot answer your question. LVN E described Resident #1 as impulsive. She stated Resident #1 was supposed to be on a pureed texture diet with thickened liquids, but he doesn't follow the diet and gets upset when facility staff attempt to take away food. LVN E stated Resident #1 would take food away from other residents in the dining room or pick up food from dirty dishes before the staff had a chance to clean it up and would start to eat the food very quickly. LVN E stated the facility interventions included constant redirection and supervision. She stated she could not remember if she had received training on meal supervision. During an interview on [DATE] at 3:59 p.m. the Social Worker (SW) stated the staff get confused with resident diets. She stated residents are always asking for soda and candy. The SW stated about one month ago a therapist/provider identified as a Behavioral Care Therapist (vendor for the facility) gave Resident #1 something he wasn't supposed to have, and the Administrator had spoken to the Behavioral Care Therapist about it. The SW stated at that time she didn't see a choking incident. The Social Worker stated Resident #1 does not have behavioral issues; he doesn't talk very much and wanders around with the wheelchair. She stated on the day of the facility Easter Celebration, everyone was told that diet was a non-issue because of the party and apparently Resident #1 ate a hot dog and choked. She stated activity department staff said, anyone can have a hot dog today. The SW stated she was not at the party when it happened but did see Resident #1 in the ambulance. She stated, I think we learned that lesson the hard way. Record review of Resident #2's face sheet dated [DATE] revealed an admitted [DATE] with a readmitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #2's physician orders dated [DATE] revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on [DATE] at 4:23 p.m., the Activity Director stated on [DATE] the facility had an outdoor Good Friday/Easter celebration with pop up tents, a DJ, raspas (snow cones), sodas, non-alcoholic beer, hot dogs with chips, an Easter Bunny and pie throwing contest. The Activity Director stated it was a free for all when staff could give all residents whatever they wanted to eat. She stated the physician puts an order in for the residents to have whatever we serve. The Activity Director stated she did have a list of residents with diet orders, so for residents on a pureed diet we would smash the hot dog with a fork and feed it to them. The Activity Director stated she was certain Resident #1 had physician ordered for pureed foods and thickened liquids because she had the diet list. She stated nursing staff was outside observing and lots of staff were there to observe. She stated, we were on top of it. The Activity Director stated she was feeding Resident #2 who was also on a pureed diet, small pieces of hot dog and the Behavioral Therapist was feeding Resident #1 slowly with lots to drink every few bites, little bites of hot dog. She stated Resident #1, and Resident #2 were not eating chips. The Activity Director stated she was right there beside the Behavioral Therapist and she (the Activity Director) was watching. The Activity Director stated Resident #1 wasn't having it with someone else feeding him. He had tendency to grab food and had to be redirected. She stated he does that. She stated he will even pick up food off the ground. She stated she didn't know what happened next, she went to sit down and heard a commotion. She stated Resident #1 must have grabbed a hot dog. The Activity Director stated she heard RN D state he isn't breathing. The Activity Director stated she had 9 staff members under her direction and the activity department puts on celebrations one time a month to every other month depending on the holidays. She stated she was unsure who did the grilling on the BBQ pit for the festivities or who provided the food. She stated she instructed staff to make sure the residents chew their food and give them drinks every few bites. The Activity Director stated she just wanted the residents to have regular texture for one day. She stated the residents were just so happy. The Activity Director stated she hoped she didn't do anything wrong, but having regular food makes the resident so happy to have just one free day. During an interview on [DATE] at 4:42 p.m. ADON D stated on [DATE] the facility was having outside activities for Good Friday/Easter when she saw Resident #1 shaking and having a [CONDITION(S)]. She stated Resident #1 did not have a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated the [MEDICATION(S)] maneuver and back blows were given to the resident by 3 different staff members. She stated Resident #1 coughed up a little bit of something, his color came back, and his eyes were open a little bit, but he was still wheezing. The ADON stated she knew something was still in his airway because of the wheezing. She stated at that time 911/EMS arrived at the facility and assumed care of the resident. The ADON stated on special occasion, like [DATE] all residents were allowed to have whatever food is served but staff have to monitor the residents closely, even residents on pureed diets. She stated the staff just monitors the residents closely. She stated she did not see Resident #1 with a hot dog, but hot dog meat did come out of him with the back blows that looked like hot dog. The ADON stated the facility served hot dogs, cups of corn and raspas (snow cones). The ADON stated a physician order was not needed for the party because it was an exception, the staff just knew they were to monitor the residents' closely. The ADON stated there was not an assignment on which staff monitored which residents. She stated monitor means staff was always out at the party. She stated, there was no schedule for monitoring. The ADON stated the event was the residents' party just for them because the facility was their house and they lived there. She stated the staff was just watching. During an interview on [DATE] at 5:02 p.m., Activity Aide H stated the facility had a party for residents on Good Friday ([DATE]). She stated during the party residents who were on pureed diets could have whatever food they wanted. She stated they could eat hot dogs (without being altered) if they wanted. Activity Aide H stated residents on mechanical diets had to have the hot dog smushed and pureed can eat the hotdog, but she didn't know if residents on a pureed diet had hot dogs. She then stated, I think I am getting mechanical soft and pureed diets mixed up. I am not sure. Activity Aide H then stated pureed diet means that the food is not hard, and it looked like mashed potatoes, pudding, or apple sauce. She stated the Activity Director had a list of residents with their diet that was given to her from the kitchen, but the Activity Director told us (Activity Aides) the residents could eat whatever at the party. Activity Aide H stated she did not have any training on feeding assistance and did not provide feeding observations of the resident. She stated when she was hired 4 months ago, she was given behavior training and instruction on what to give residents and what not to give residents food wise. She stated she had not received any training or in-services since the choking accident with Resident #1. During an interview on [DATE] at 5:42 p.m. the Activity Assistant stated the facility had special occasion parties approximately 1 time a month or every other month. He stated the activity department received a list of physician-ordered diets for each resident from the kitchen. The Activity Assistant stated resident on pureed diets and mechanical soft diets had to be watched to ensure they did not aspirate. The Activity Assistant stated all activity staff were monitoring the party and CNA staff helped out when they could. He stated on [DATE] he was wearing a bunny suit and was not monitoring residents. He stated it was just activity staff and a few CNA's monitoring the party. He stated he did not see any nurses outside, but he wasn't aware of the choking incident with Resident #1 when it occurred. The Activity Assistant stated he did not know how many staff ere outside. He stated the Activity Director was outside, the DON came out occasionally, the Behavioral Therapist and the Social Worker were there. The Activity Assistant stated there were physician orders for residents to each whatever they wanted from the Medical Director. He stated that was the same way it had always been at the facility since he started in 2013. The Activity Assistant stated the Activity Aides will help feed residents occasionally but were not entirely qualified to provide feeding assistance because most of them were waiting to go to CNA class, although he was a CNA. During an interview on [DATE] at 6:04 p.m. the DON stated Resident #1 had a legal guardian because he had been found {mentally} incompetent by a court. He stated the resident had behaviors which included persecutory delusions and paranoia which the doctors think is a progression of his disease. The DON described Resident #1 as independent minded and defiant. He stated the resident grabs food off the trays, when staff were putting away food, he grabs the food. He stated the staff redirect him. The DON stated his behaviors were care planned. The DON stated recently Resident #1 was sent to the hospital after food did not agree with him. The DON stated Resident #1 was a full code and on hospice. He stated on Good Friday ([DATE]), the DON didn't know what the resident ate but saw Resident #1 could not breathe and had circumoral cyanosis (the appearance of blue skin in the area around the mouth which can signify low oxygen levels in the blood). The DON stated the [MEDICATION(S)] maneuver was performed while he was sitting up and then suddenly Resident #1 went limp. The DON stated he performed back blows to help dislodge what was blocking the resident's airway. The DON stated after the back blows the resident began breath, was placed on oxygen. The DON stated EMS were able to dislodge the obstruction. The DON stated he did not tell activities that resident could eat whatever they wanted. The DON stated before every event we instruct staff. He stated we do not want them to not enjoy the festivities, but we want them to have some level of safety. He stated residents on puree texture need to have foods down as much as we can to pureed and that included blending. He stated we cut up very small pieces of food and the residents get only the pieces. The DON stated pureed food consistency was like pudding. He stated there was no way to make hot dogs like pudding without blending them up, so they crushed them with a fork as much as possible until it was smooth enough for Resident #1 to handle. The DON asked, was it smooth enough for him to handle? He then stated, with staff verbal cueing and reminding Resident #1 to chew his food, I think he was okay. The DON stated at the party facility staff took a whole hot dog away from the resident earlier in the day. He stated, we have to be vigilant with Resident #1. The DON stated, knowing his behaviors of stealing food is how we keep him safe by monitoring him and redirecting him. The DON stated he was supervising the party for all but 20 minutes when he had to come inside for a meeting. He stated the activity staff, CNA's and some nursing staff was outside. He stated there was not an assigned scheduled for supervision, but ADON G, LVN E and RN D were all outside at some point. He stated the nurses would come and go but tag teamed so somebody was outside. The DON stated activity staff do not monitor meals, but they do monitor snacks. He stated activity staff know the different consistencies of meals because the Activity Director and Speech Therapist went over it with them (date unknown). The DON stated residents' usually have to have an order from a physician for a special or altered diet. The DON stated Resident #1 had a physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . He stated Resident #1 did not have physician orders for special events or modifications from the pureed diet. The DON stated he did not know if the staff had received any in-service training on diets since the choking incident. He stated they might have started one. He stated the week before they had completed dietary order checks for accuracy. During an interview on [DATE] at 7:05 p.m. the Administrator stated he was outside at the party ([DATE]) when he saw Resident #1 grab a hotdog and tried to stuff it down his throat. The Administrator stated he told staff (unknown) to supervise the resident. The Administrator stated he saw Resident #1 coughing after consuming the hot dog at approximately 3:00 p.m. He stated approximately 10 minutes later Resident #1 looked unresponsive. The Administrator stated the DON took Resident #1 inside the facility and did the [MEDICATION(S)] maneuver and cleared meat from his airway. He stated 911 was called for an evaluation. The Administrator stated Resident #1 was breathing when he left the facility. The Administrator stated residents can eat whatever was served at the parties, but the food consistency must remain the same (as ordered by a physician). He stated the kitchen prepared food for special diets. The Administrator stated he was not aware staff was not changing the consistency of the diet at the event. He stated most residents on altered diets don't participate in the activity meal. The Administrator stated Resident #1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The Administrator stated activity staff do not serve meals, although the Activity Director did have a list of physician-ordered diet consistency for each resident. He stated activity staff also do not feed the residents. He stated they only observe snacks for resident without diet restrictions. The Administrator stated since the choking incident on [DATE] he had not given a formal in-service to facility staff. He stated he just talked to staff who were at the event and told them to provide constant supervision. The Administrator stated he did ask the DON and ADON J to perform diet audits to make sure they matched what was coming out of the kitchen. He stated he had also talked to the DON about doing a CPR in-service, but nothing had been started or completed. The Administrator stated the computer-based training program titled Safe swallowing and feeding techniques was not scheduled to be assigned to staff, primarily CNA staff until October of 2022. The Administrator stated he monitors the facility for food safety by performing audits, monitoring tray cards, providing dietary consults. He stated they talk about issues or concerns in morning meetings where the Dietary Manager and Activity Director bring concerns. The Administrator stated in order for staff to protect residents from food stealing behaviors, snacks should be kept behind the staff member in a controlled area. The Administrator stated when residents who have food stealing behaviors are outside, two activity staff should observe. During meals, these residents should be brought to the dining room where their food tray should be served immediately. The Administrator stated Resident #1 understands not yours and redirects easily. During an interview on [DATE] at 12:00 p.m. the Behavioral therapist stated she had seen Resident #1 clinically in the past a couple of times. She stated Resident #1 was more alert than people thought. The Behavioral Therapist stated she was at the party on [DATE] interacting with residents in a clinical manner. She stated she saw Resident #1 eat a hot dog with the bun and weenie. She stated she took the bun away from the resident and fought him for the weenie. She stated she tried to get the food stuff out of his mouth as he was stuffing it into his mouth. The Behavioral Therapist stated she also saw a staff member (unknown) on a separate occasion at the party take a hot dog away from Resident #1. The Behavioral Therapist stated she did not feed any of the residents. She stated, I think there was a misconception of what occurred, and I can see why they thought I was feeding him. She stated she put her finger in his mouth and performed a sweeping motion to try to get food out of his mouth, which she demonstrated. The Behavioral Therapist stated she does not think staff were feeding any of the resident either because she never saw staff feeding Resident #1. She stated Resident #1 just took the food, and he was quick. She stated all the other residents fed themselves and did their own thing. The Behavioral Therapist stated she did see staff giving Resident #1 drinks including sodas and Near Beer (nonalcoholic beer like beverage). She stated the beverages were not thickened. The Behavioral Therapist then stated she did remember during the interview that she did feed Resident #1 corn kernels