SOLIDAGO HEALTH AND REHABILITATION

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide pharmaceutical services that assure accurate acquiring, dispensing, and administering of all drugs and biologicals to meet the needs of residents for each resident 1 out of 8 (Resident #3) residents reviewed for pharmacy services. in that:<BR/>-The facilityNF failed to administer Resident #3's insulin Lantus as ordered by the physician . Resident #3 did not experience actual harm.<BR/>This failure could placed Residents #3 at risk for hyperglycemia, diabetic ketoacidosis, and hospitalization.<BR/>Findings included:<BR/> Record review of Resident #3's face sheet revealed a 63year old male resident was admitted to the NF on 01/21/2022. The resident's with the following diagnoses that included Type 2 diabetes mellitus with diabetic polyneuropathy (nerve damage from pain and numbness in feet to issues with the functions of internal organs such as the heart and bladder), end stage renal disease (kidney disease), dependence on renal dialysis, absence of left leg below knee, hypertension (elevated blood pressure), and heart failure. <BR/>Record review of Resident #3's MDS dated [DATE] revealed that resident had a BIMS score of 14 indicating that resident's cognition was intact.<BR/>Record review of Resident #3's Care Plan dated 02/15/2023 revealed that resident was being care planned for risk for hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar) related to diagnosis of diabetes mellitus. Resident interventions included administer medications as ordered per MD, evaluate/record/report effectiveness/adverse side effects. Further review did not reveal that resident was being care planned for refusing his insulin. <BR/>Record review of Resident #3's Physician Orders revealed the following orders:<BR/>-dated 12/06/2022 dialysis Tuesday, Thursday, and Saturday<BR/>-dated 02/08/2023 Lantus 20 units subcutaneous (beneath the skin) for diabetes mellitus once a day at 7:00am<BR/>-dated 02/07/2023 Blood glucose checks twice a day at 7:00am and 8:00pm<BR/>-dated 04/12/2023 for a hemoglobin A1C (blood test that measures your average blood sugar levels over the past 3 months).<BR/>Record review of Resident #3's Nursing Progress Notes dated 04/10/2023 documented by LPN T revealed in part:<BR/> .Resident refused scheduled long actin insulin. PA notified. Blood sugar was 130 at breakfast time. Checked resident's blood sugar at lunch 179. Resident is in stable condition resting in bed eyes closed call light in reach. Will continue to monitor .<BR/>Further review of Resident #3's Nursing Progress Notes dated 04/11/2023 documented by LPN T revealed in part:<BR/> .Resident refused insulin due to no appetite and his scheduled dialysis day. Blood sugar 137 resident is resting eyes closed stable condition shows no s/s (signs or symptoms) of pain or discomfort will continue to monitor. Family and PA (Physician Assistant) notified . <BR/>Record review of Resident #3's MAR for January 2023 revealed on dialysis days the insulin Lantus was not administered on 8 dialysis days (01/02/23, 01/05/23, 01/14/23, 01/17/23, 01/19/23, 01/24/23, 01/26/23, and 01/28/23). Resident insulin was held on 2 non-dialysis days (01/02/23 and 01/04/23). Resident blood sugars on following days:<BR/>-01/02/23: Blood sugar at 7:00am 168, 8:00pm 163<BR/>-01/05/23: Blood sugar at 7:00am 106, 8:00pm 170<BR/>-01/14/23: Blood sugar at 7:00am 128, 8:00pm 205<BR/>-01/17/23: Blood sugar at 7:00am 97, 8:00pm 150<BR/>-01/19/23: was not documented done at 7:00am. at 8pm blood sugar 230 <BR/>-01/24/23: was not documented done at 7:00am at 8pm blood sugar 125<BR/>01/26/23: was not documented done at 7:00am at 8pm blood sugar 191<BR/>01/28/23: Blood sugar at 7:00am 129 at 8pm blood sugar 134 <BR/> Record review of Resident #3's MAR revealed for the month of February 2023 the insulin Lantus was held 4 times on dialysis days (02/02/23, 02/21/23, 02/25/23, and 02/28/23) with blood sugar ranging from 93-238. Resident insulin was held 1 time on non-dialysis day (02/24/23) resident blood sugar at 7:00am was 90 and at 8:00pm blood sugar was 224. <BR/>Record review of Resident #3's MAR for the month of March 2023 revealed that the insulin Lantus was held on 8 dialysis days (03/02/23, 03/04/23, 03/07/23, 03/09/23, 03/11/23, 03/14/23, 03/16/23, and 03/18/23), with resident blood sugars ranging from 82-289 and on non-dialysis days the insulin was held 6 days (03/01/23,03/06/23, 03/08/23, 03/12/23, 03/17/23, 03/19/23, with resident blood sugars ranging from 94-246. <BR/>Record review of Resident #3's MAR for the month of April 2023 revealed that resident did not receive insulin on 4 dialysis days (04/01/23, 04/04/23, 04/06/23, and 04/11/23) with blood sugars ranging from 120-254 and 2 non-dialysis days with blood sugar ranging from 92-234. <BR/>Interview on 04/10/2023 at 12:50pm, LPN T said she was working the 100-Hall and was Resident #3's nurse. Further interview with LPN T said Resident #3's blood sugar was 130 at 7:00am and anytime it was below 150 she would hold resident's morning insulin Lantus because she was familiar with resident's food consumption. The surveyor asked LPN T if it was the physician order to hold resident insulin Lantus? LPN T said there was not an order to hold resident insulin Lantus, she just done it that way. LPN T said she did not notify the physician about holding Resident #3's insulin and that Resident #3 and herself agreed to hold the insulin when resident blood sugar was below 130. <BR/>Interview on 04/11/2023 at 1:49pm, LPN T said on the days that Resident #3 did not receive his insulin for the month of April was because resident had refused and that she had documented. <BR/>Interview on 04/11/2023 at 2:13pm thepm, the mobile DON said that if a resident was refusing their insulin as ordered by the physician, the physician should be notified so that interventions could be put in place to better care for the resident.<BR/>Interview on 04/11/2023 at 3:05pm via phone with the NP for Resident #3, he said no one from the NF had called him regarding Resident #3 refusing his insulin on 04/10/2023 or any other day. The NP said if Resident #3 had been refusing his insulin, he would first talk to the resident educating resident on the benefits of taking his insulin before making any changes to his medications. Further interview with the NP said Resident #3 did not have PA (Physician Assistance) just himself and the doctor.<BR/>Interview on 04/12/2023 at 9:00am with the mobile DON and ADON stated confirmed that Resident #3 had a NP that came to see him and not a Physician Assistance.<BR/>Interview on 04/12/2023 at 9:20am with the RP for Resident #3 stated confirmed that they had never received a call from the NF on 04/10/23 or any other day that resident was refusing his insulin, or that resident insulin was being held on certain days. <BR/>Observation on 04/12/2023 at 9:46am Resident #3 sitting in wheelchair at the front entrance of the NF wearing street clothing. Resident #3 had a left below the knee amputation (removal of a limb). <BR/>Interview on 04/12/2023 at 9:46am, Resident #3 said he went to dialysis on Tuesday, Thursday, and Saturday. Resident #3 said he sometime refused his insulin on these days because he sometimes did not feel good but did not refuse his insulin on Monday 04/10/2023.<BR/>Interview on 04/12/2023 at 10:05am, LVN X said if a resident refused their insulin, she would notify the doctor/NP and document the happenings.<BR/>Interview on 04/12/2023 at 10:42am via phone RN U said the reason she did not administer Resident #3's morning insulin Lantus on 04/04/2023 was because resident was scheduled to go to dialysis. RN U said she was afraid resident might become hypoglycemic (low blood sugar) and therefore held resident insulin. RN U said she did not inform the doctor/NP of her holding the insulin and that it was nursing judgement.<BR/>Interview on 04/12/2023 at 11:30am, the mobile DON said she had reviewed Resident #3's MAR for 04/09/2023 and saw where resident insulin Lantus was not being administered as order by the physician. The mobile DON said she had begun to in-service the nurses on administration of insulin. The mobile DON said when insulin wasis not administered as order by the physician, resident blood sugar readings would not be consistent but up and down. The mobile DON said nurse LPN T could not come back to the NF to work and that the NF had suspended LPN T pending further investigation. The mobile DON said LPN T could not be trusted to work at the NF.<BR/>Further interview on 04/12/2023 at 11:48am, the NP said he learned from the surveyor and speaking with Resident #3 on 04/12/2023 that the insulin Lantus was not being administered as ordered. The NP said by not administering resident insulin as ordered placed resident at risk for becoming hyperglycemic (increase in blood sugar) or go into diabetic ketoacidosis (when the body does not have enough sugar to meet its energy needs, it will break down fat instead) which was not good. The NP said he would look at possibly making changes to resident insulin on dialysis days but first had to draw labs to see what resident Hemoglobin A-1 C level was. <BR/>Further interview on 04/12/2023 at 12:38pm, the mobile DON said it was herself and the ADON that monitored the resident MARs to ensure that the physician orders were being followed. The mobile DON said she had been working at the NF for 4 weeks. The mobile DON said how herself and the ADON was checking the MARS by reviewing the facility report that showed if all medications had been administered or not given. The mobile DON said she discovered that Resident #3 insulin was not being administered as ordered by the physician on 04/09/2023. The mobile DON said she began to in-service the staff regarding following physician orders and notifying the doctor when a resident (s) insulin is held or if the resident refused the medication.<BR/>Record review on 04/12/2023 of in-service done with the NF staff on insulin medication administration documentation, 5 rights of medication administration, and when a resident refuses to take insulin the doctor and RP must always be notified, dated 04/10/2023. <BR/>Record review of physician orders for residents on dialysis revealed that Resident #3 was the only resident that received insulin.<BR/>Interview on 04/13/2023 at 1:55pm, the ADON said the NF ran a facility report on the MARS each morning and it was reviewed by herself and the DON. The ADON said if a resident refused their insulin, the unit nurse should be calling the physician to notify that resident refused their insulin. The ADON said she had to be honest that due to her being pulled in so many directions and the only ADON, she had not had time to review the facility report and follow-up with the nurses to ensure that physician orders were being carried out. The ADON said LPN W was and Agency nurse. The ADON said she did not know if the NF had in-serviced agency staff on notifying the physician if a resident refused their insulin or if the insulin had to be held. The ADON said she was never involved in any in-services or training with agency staff. <BR/>Interview on 04/13/2023 at 2:50pm, RN V said she worked at the NF PRN. RN V said she remembered caring for Resident #3. RN V said if the medication insulin was held, she documented that she notified the doctor via text or phone. The surveyor informed RN V that the surveyor was unable to locate in the Nursing Progress Notes that Resident #3's physician or NP had been notified of insulin refusal or that the insulin was held until 04/10/2023 by LPN T. LPN T did not respond after the surveyor informed her of this. <BR/>Further interview on 04/13/2023 at 4:35pm with the NP said he had reviewed Resident #3 blood sugars and resident blood sugars were good overall. The NP said he had ordered a hemoglobin A1C 3 days ago and was waiting on the results. <BR/>Record review of Resident #3's Hemoglobin A1C labs revealed the following:<BR/>-dated 04/16/2023 reading 6.3 (normal range 4.5-5.7)<BR/>-dated 11/20/2022 reading 6.0<BR/>-dated 06/27/2022 reading 5.1 <BR/>Interview on 04/17/2023 at 1:05pm, the Regional Nurse and mobile DON said it was the responsibility of the DON to ensure that staff was being trained and in-serviced on when to notify the physician of any changes regarding the residents medical care including refusal of medications or if a medication his held. The mobile DON said she could not locate the staff training/in-service binder for the NF. The DON said the NF had not had a steady DON for a while. <BR/>Attempted interview on 04/17/2023 at 1:45pm via phone with LPN W regarding Resident #3's insulin not being administered as ordered, no answer, left voicemail with a call back number.<BR/>Interview on 04/17/2023 at 1:50pm via phone LPN W said she was an agency nurse that had been coming to work at the NF for about 2 months on a prn basis (as needed). LPN W said she had not received any in-service on when to notifying the physician regarding medications. LPN W said she did not remember Resident #3. LPN W said if she held insulin Lantus, it was a nursing judgement call and that she did not call the doctor every time she held insulin. <BR/>Interview on 04/19/2023 at 10:30am, the mobile DON and the Regional Nurse said the NF did not have a policy on insulin administration. The surveyor asked the mobile DON and Regional Nurse for the NF policy on management of medication administration for dialysis residents. The Regional nurse said she would have to look and see if the NF had such a policy. The mobile DON said Resident #3 was the only dialysis resident that had an order for insulin. The mobile DON said she had done in-service on blood glucose monitoring check off list with the staff and in the following weeks she would be ensuring that all staff had their competencies check off list done. The DON said she would be doing a QAPI (Quality Assurance Performance Improvement) and PIP (Performance Improvement Project) on insulin administration. <BR/>Interview on 04/19/2023 at 10:48am, the Doctor for Resident #3 said he and his NP were the only medical health care providers that gave orders on Resident #3 at the NF. The doctor said he learned from his NP that the Nursing staff at the NF werewas not administering resident's insulin Lantus as ordered. The doctor said a conversation needed to be had with him and the NF regarding resident refusing medication Lantus, that he could look at other alternatives involving resident medication.<BR/>Interview on 04/19/2023 at 11:08 am, the Pharmacist said she came to the NF each month and that she was coming to the NF on 04/20/2023 to do the NF Drug Regimen Review. The Pharmacist said she had been working at the NF for 6 months and that the NF had 4 DON's working at the NF in that time frame. The Pharmacist said she reviewed Resident #3's medications on last month and did not make any recommendations. The Pharmacist said she did not review the residents MARS because she did not have access to the MARS therefore did not know that the nursing staff was not administering resident insulin as ordered by the physician. The Pharmacist said the nursing staff should not have been holding Resident #3's Lantus unless they had parameters given by a physician. The Pharmacist said it would have been okay to administer the insulin on dialysis days. The Pharmacist said if she had known that Resident #3 was refusing his insulin-on-dialysis days, she would have made a recommendation to the doctor to administer the insulin in the evenings after dialysis that way resident could still receive the insulin. The Pharmacist said when the insulin wasis not administered as order, the blood sugar level could rise damaging the kidneys further and Resident #3 was already on dialysis. <BR/>Record review of the NF Policy on Medication Management Program revised 2017 revealed in part:<BR/> .The facility implements a Medication Management program to meet the pharmaceutical needs of patients and residents, according to established standards of practice and regulatory requirements .The facility will collaborate with the Medical Director and the attending physician on the application of the drug formulary and therapeutic change . <BR/>Record review of the NF Policy on documentation-Licensed Nursing pertaining to the patient/resident will be recorded with regulatory requirements revised in 2017 revealed in part:<BR/> .If a scheduled medication is withheld or not give as ordered, the nurse documents this and list the reason for the patient/resident not receiving the medication. The attending physician or physician extender must be notified. Route must be charted .

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

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in the only facility kitchen.<BR/>The facility steam tray water reservoir and glass covering, were dirty.<BR/>The facility failed to clean the floor of the walk- in dry storage room.<BR/>The facility failed to change the grease in the deep fryer.<BR/>The deep fryer, overhead hood of the stove, stovetop, and burners were dirty. <BR/>The facility failed to repair the drainage system for 2 drains in the kitchen cooking, preparatory and meal service areas. <BR/>These failures could place the residents who ate meals prepared in the kitchen at risk for food borne illness.<BR/>Findings included:<BR/>During observations on 2/19/23 at 11:55 a.m., the grease in the deep fryer was dark brown with food debris. The sides of the deep fryer were dirty with black and white streaks down the sides. The overhead hood had globules of brown grease hanging from the brim of the metal hood. The stove cook top was dirty with crumbs and dark grease build up on each eye of the 6- burner stove, as well as the metal backsplash of the stove. There was 1 grey singed oven mitt on the metal overhang above the stove. The floor drain in front of the stove range and the deep fryer had an oatmeal type substance bubbling out of it and surrounding the metal corrugated top of the drain. There were small black gnats flying around it. There was a second drain near the food prep area that had the same oatmeal like material surrounding the drain that appeared dried. Continued observation of walk-in dry storage room with black streaks, skid marks and footprints observed all over the floor. There was only 1 kitchen staff member who was preparing the lunch time meal service and the last steam tray water reservoir to the right, was a turbid brown with a white residue floating on top of it, like a film. The glass to the steam table was cloudy, streaks, spots, speckles, and a hazy film covering the glass. <BR/>During an interview on 2/19/23 at 12:15 p.m., with an anonymous staff A who said the oil in the deep fryer needed to be changed. They said it had not been done because they had been working all morning alone. They said that the entire kitchen needed to be cleaned and that the night FSS were responsible for cleaning the deep fryer, stove and basically everything that was dirty including the floors in the walk-in dry storage room, the sides of the deep fryer and stove hood as well as the burners on the stove. They said that the 2 drains had been backing up for at least 2 weeks and that the administrator had been aware because it was repeatedly reported to her by several staff including the old DM and MD. They said that several staff had quit within the last few weeks, and that the administrator said she would fix things, but things never got fixed. They said they did not know why or how the oven mitt on the top of the metal overhang of the stove got burned or singed and said they had not used them that day and did not know when they had been laundered last. They said the steam table should have been cleaned by the evening/night FSS and did not know when the steam tray or glass had been cleaned.<BR/>During an interview and observation of facility kitchen with Administrator and FSS on 2/19/23 at 1:44 p.m., When the Administrator was shown the dark brown grease in the deep fryer and the food debris, she shook her head. When asked if it needed to be cleaned and the grease changed, she shook her head yes. When shown the brown globules of grease hanging from the brim of the metal hood over the soiled and dirty stove and backsplash and the bubbling drain in front of the deep fryer and stove, she said that on 2/16/23 the maintenance assistant fixed the drainage/plumbing issue and that 2/16/23 was the first time she heard anything about the issue. She said that she had been in the kitchen on 2/17/23 and did not see any drainage or residue on the floor or residue on the floor around the drains or any backflow from the floor drains. When asked if the deep fryer, stove, metal backsplash, steam table tray, vent hood, walk- in dry storage floor and overall kitchen appearance was the same, she did not answer the question. When asked if the kitchen was in the same condition on 2/17/23 as it was on 2/19/23 she did not reply. The Administrator said that the DM quit on 2/7/23 and that the former Maintenance Director's last day was 2/10/23. She said that the evening/night FSS were responsible for cleaning the kitchen and had a cleaning schedule they were to follow. The Administrator said that the kitchen and all the items observed should have been cleaned and the grease in the deep fryer changed. The Administrator said the kitchen needed to be cleaned. She said that the DM was responsible for ensuring that the kitchen was cleaned and that if there were no DM, she would be ultimately responsible of ensuring that it was done. The Administrator did not know when the last deep cleaning or cleaning schedule had been completed. Surveyor requested a copy of completed deep cleaning and or cleaning schedules that had been documented as completed by FSS, from the Administrator at that time and did not receive them prior to exit. <BR/>Interview and observation with FSS B, on 2/19/23 at 1:46 p.m., who was unsure how long the 2 drains had been backing up onto the kitchen floor but said that the former Maintenance Director had tried to fix the issue before he stopped working at the facility. FSS B said that only 2 of 4 drains were affected and only when they ran water in the kitchen in the preparatory sink or ran the dish machine. FSS B said that the evening/night FSS were responsible for cleaning the kitchen and did not know why there had been no one completing the cleaning as scheduled or ensuring that someone else completed the cleaning per the schedules.<BR/>Record review of an incomplete, undated The [NAME] Deep Clean Schedule provided by Administrator on 2/19/23 at 1:44 p.m., read as follows: PM Sunday-Fryer (drained, completely cleaned, replace oil, scrub the whole thing inside and outside clean with degreaser) .PM Monday-Stove/Oven (burners to be taken off and cleaned, shelf and backsplash clean and wipe with degreaser, doors and sides clean and wipe with degreaser, inside oven scrubbed clean, oil drip tray scrubbed clean with degreaser) .PM Wednesday-Scrub floor (scrub floor form backsplash to steamtable, from reach in to coffee station) .AM Saturday- Steamtable (around wells need to be scrubbed clean, on top of shelf and under shelf needs to be scrubbed clean, sides and where knobs are need to be scrubbed and cleaned, pull everything out from bottom shelf and needs to be scrubbed and cleaned with degreaser.<BR/>Record review of undated Nutrition Orientation & Competency Policies And Procedures provided by Administrator on 2/19/23 at 1:44 p.m., read in part: FLOORS .There is usually an established routine for cleaning the floors in the food areas. It is important to maintain this routine to assure a clean Nutrition/Culinary Services Department. The routine usually includes sweeping several times a day and mopping at least once a day.<BR/>Record review of The Food and Drug Administration Codes October 2015, 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils indicated:<BR/> . (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch. <BR/>(B) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. <BR/>(C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue and other debris .

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

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

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

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain personal hygiene for 1 (Resident #4) of 8 residents reviewed for incontinent care.<BR/>-The facility failed to ensure Resident #4 was provided incontinent care in a timely manner.<BR/>This failure could place residents at risk for urinary tract infections, further decrease in skin integrity, and unwanted hospitalization.<BR/> Findings included:<BR/>Record review of Resident #4's Face sheet revealed an 80year old male admitted to the NF originally on 01/28/2021 and again on 04/13/2022. Resident #4's diagnoses included Parkinson's Disease (A chronic disease that effects muscle movement and coordination) , dementia (decline in mental function), bilateral (both sides) primary osteoarthritis (wearing down of tissue around the bone joints) of knee, pain, and peripheral vascular disease (circulation disorder involving the arteries or veins narrowing and restricting blood flow). <BR/>Record review of Resident #4's Physician orders dated 11/26/2022 had an order to apply barrier cream to sacrum every shift after each incontinent episode. Further review revealed an order dated 04/11/2023 to clean left buttock wound with NS (normal saline), pat dry, cover with calcium alginate and apply dry dressing daily.<BR/>Record review of Resident #4's MDS dated [DATE] revealed that resident BIM's score was 3 indicating that resident cognition was severely impaired. Further review revealed that resident required extensive assistance with bed mobility, eating, and was total dependence with transfer, dressing, toilet use, and personal hygiene. Further review revealed that resident was always incontinent of bowel and bladder <BR/>Record review of Resident #4's Care Plan dated 04/18/2022 and updated 03/13/2023 revealed that resident required assistance to complete ADL task due to impaired cognition, impaired mobility and incontinence, personal hygiene, toileting with 1-2 person assist by CNA, license nurse, nursing, Registered Nurse (RN).<BR/>Observation on 4/21/23 at 9:50 a.m., Resident #4's room smelled of urine. <BR/>Interview on 4/21/23 at 10:00am with CNA R, she stated residents were to be repositioned and provided incontinent care every two hours. She stated today she didn't change Resident #4 because she wasn't working the front of the hall where his room was. Her shift today was 6am to 2pm. She had not changed him today.<BR/>Observation on 04/21/2023 at 10:30am, Resident #4 was in his bed resting on his back on an air mattress. Resident was not inter-viewable. Resident's room had a strong urine odor.<BR/>Interview on 04/21/2023 at 10:35am, CNA S said she was the CNA for Resident #4. CNA S said she worked full time on the 2pm-10pm but was called in to work for the 6am-2pm shift because a CNA had to leave on the 6am to 2pm shift. CNA S said she had made it to the NF around 9am or a little after. CNA S said when she arrived to the NF, the CNA that was caring for Resident #4 had already left the NF, therefore she did not receive a report from the CNA or the nurse caring for Resident #4. CNA S said when she arrived at the facility, she made rounds making sure all the residents were breathing and not in any distress but did not check to see if any residents were incontinent of bowel or bladder instead, started passing the breakfast trays.<BR/> Observation on 04/21/2023 at 10:45am revealed incontinent care for Resident #4 done by CNA S with the assistance of the Unit Manager. Resident #4 was wearing a brief that was heavily soiled with urine and had a bowel movement. <BR/>Interview on 04/21/2023 at 12:42pm CNA S said the last time she had received in-service on incontinent care she believed was last year of 2022. CNA S said the residents should be checked for incontinent care at least every 2 hours. <BR/>Interview on 04/27/2023 at 4:00pm, the ADON said the CNAs should be providing or checking the residents for incontinent care at least every 2 hours and as needed. The ADON said for those residents that were heavy wetter's, the CNAs should be checking more frequently than every 2 hours for incontinent care. Further interview with the ADON said herself and the DON done in-service with the staff regarding resident care. The ADON said she had not provided any in-service to the CNA's regarding incontinent care. The ADON was unable to find in-service done with the CNA's regarding incontinent care. The ADON said the NF had just hired a new DON. <BR/>Record review of the NF Policy on Quality-of-Life revised 2017 revealed in part:<BR/> .The facility will promote a quality of life for patient's/residents .The facility staff will assist patient/resident in activities of daily living .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident with pressure ulcer receives necessary treatment services consistent with professional standards of practice to promote healing, prevent infection, and prevent new pressure ulcers from developing for 1 of 8 residents (Resident #4) reviewed for pressure ulcers in that:<BR/>-The facility failed to do weekly skin assessments on Resident #4.<BR/>-The facility delayed in getting wound care orders for Resident #4 when resident's skin to the sacrum went from redness to stage II.<BR/>-The facility failed to place an air mattress on Resident #4's bed when it was documented that Resident #4's Braden scale revealed High Risk for pressure ulcers. <BR/>This failure placed resident at risk for further skin breakdown, infections, and pain. <BR/>Findings:<BR/>Record review of Resident #4's face sheet revealed an 80yearold resident admitted to the NF initially on 01/28/2021 and again on 04/13/2023. Resident's diagnoses included the following: Parkinson's Disease (brain disorder that leads to tremors, stiffness, and difficulty with balance and coordination, dementia (impairment of memory and loss of judgement), type 2 diabetes mellitus, hypertension (elevated blood pressure), peripheral vascular disease (narrowing of the blood vessels reducing blood flow to the limbs), and osteoarthritis of knee (tissue around the bone joints begin to wear down causing pain and loss of movement). <BR/>Record review of Resident #4's physician orders included the following:<BR/>-dated 05/03/2022 consult hospice of patient/family choice<BR/>-dated 05/19/2022 admit to hospice diagnosis Parkinson's Disease<BR/>-dated 11/26/2022 apply barrier cream to sacrum every shift after each incontinent episode every shift<BR/>-dated 04/11/2023 clean left buttock wound with NS (normal saline), pat dry, apply, cover with calcium alginate (cream substance to promote wound healing) and apply dry dressing daily (this order documented was given by Resident #4's doctor at the NF). <BR/>-dated 10/04/2022 ST (Speech Therapist) to evaluate and treat as indicated<BR/>Record review of Resident #4's MDS dated [DATE] revealed that resident's BIMS score was a 3 indicating resident's cognition was severely impaired. Further review revealed that Resident #4's functional status section G of the MDS revealed that resident required extensive assistance with mobility and eating. Resident was totally dependent upon staff with transfer, dressing, toilet use, and personal hygiene. Further review of skin conditions section M of the MDS revealed that resident was at risk for developing pressure ulcers and did not have any pressure ulcer.<BR/>Record review of Resident #4's Care Plan dated 04/18/2022 and revised on 03/13/2023 revealed that the NF was only care planning resident for risk for skin breakdown with the intervention to report any skin breakdown (sore, tender, red, or broken areas).<BR/>Record review of Resident #4's Nursing Progress Notes from January 2023 to April 20th, 2023, did not mention any assessment of resident having skin breakdown. Further review revealed that on 04/07/2023 documented by RN ZZ revealed in part:<BR/>Hospice nurse is here to see resident, assessment completed .<BR/>Record review of the NF 24-hour report sheet for the month of April 2023 did not reveal any skin breakdown for Resident #4, just that resident was stable and being seen by hospice services. <BR/>Record review of Resident #4's Braden Scale (for predicting sore risk) dated 01/23/2023 revealed a score of 12 (HIGH RISK) for predicting pressure sore risk. <BR/>Further review of Resident #4's Braden Scale dated 03/22/2023 revealed an 11. The interpretation of score as follows:<BR/>-19 or higher, no risk<BR/>-15-18 at risk-if other major risk factors are present e.g. advanced age, fever, poor dietary intake of protein, diastolic less than 60<BR/>-13-14 moderate risk-if other major risk factors are present<BR/>-10-12 HIGH RISK<BR/>-9 VERY HIGH RISK <BR/>Record review of the FACILITY and HOSPICE DECLINEATION of DUTIES signed 05/10/2022 revealed in part:<BR/> .Durable Medical Equipment required/Provided (hospice list included suction, nebulizer, and oxygen concentrator) . Nrsing list included bed and OBT (overbed table) . Further review of the delineation of duties revealed that both hospice and the NF checked the yes box to perform wound care as follows: per facility protocol. <BR/>Record review of Resident #4's weekly skin assessments revealed: <BR/>4/11/23 completed by RN ZZ revealed, new wound to sacrum, new orders given, assessed by hospice nurse, today area is approx. 4cm long, 3.5 cm wide, no drainage, surrounding area is ashen in color with a beefy red center, per hospice RN wound is unstageable<BR/>There was not a weekly skin assessment completed for the week of 4/2/23 through 4/8/23<BR/>3/28/23 completed by former wound care nurse- no skin issues noted.<BR/>Record review of Resident #4's MAR for April 2023 revealed a weekly skin assessment was completed on 4/4/23 by LVN U.<BR/>Observation on 04/21/2023 at 10:30am, Resident #4 was in bed resting on his back. Resident had an air mattress on his bed. Resident was not inter-viewable.<BR/>Interview on 04/21/2023 at 10:32am, the mobile DON said the NF did not have a wound care nurse and that the Unit Manager was doing the wound dressing changes at the NF.<BR/>Interview on 04/21/2023 at 10:40am, the Unit Manager said she had changed Resident #4's dressing to his sacral wound earlier in the am. The Unit Manager said she did not know when Resident #4 acquired the pressure ulcer to the sacral area and that today was her first time seeing the wound to resident sacral area. The Unit Manager said an air mattress was placed on resident's bed approximately 3 days ago and that hospice was overseeing resident wound to his sacrum.<BR/>Further interview on 04/21/2923 at 10:50am, the Unit Manager said she was Resident #4's primary care nurse in the past when she worked the 200-Hall. The Unit Manager said she could not remember when the last time she cared for Resident #4 and had never done a skin assessment on the resident. The Unit Manager said skin assessments were done weekly by the unit nurses. The Unit Manager said she mainly worked hall 300 but had to float sometimes to other halls to work. The Unit Manager said she was just promoted from a staff nurse to Unit Manager on 04/21/2023 and wound care nurse. The Unit Manager said skin assessments were done on Hall 300 on Wednesdays and Hall 200 skin assessments were done on Tuesdays. The Unit Manager said if a CNA saw a change in a resident skin or change in resident condition, the CNA should report the change to unit nurse working that specific hall. The Manager said the nurse would document the change on the 24-hour report sheet as well as notifying the physician to get treatment for the wound. The Unit Manager said the ADON reviewed the 24-hours report each morning. <BR/>Observation on 04/21/2023 at 12:20pm, lunch tray was delivered to Resident #4's room. Resident was served a pureed diet that consisted of the following foods: chicken, potato's, green beans, and pudding for dessert with tea as a beverage. Resident #4's family members were present at the bedside. Further observation was made of the family assisting resident with food to eat bought in to the facility. <BR/>Interview on 4/21/23 at 12:27 p.m. with CNA Y, she stated Resident #4 had a sore on the behind area. She said the last time she worked the hall was over a week ago when she worked that hall. She said when she provided incontinent care he didn't' have a bandage on it. She said she knew the nurse was aware of it because she had reported to the nurse. She said it was a circular wound, and guessed the diameter was about 2 inches, and it was open. She stated she believed everyone knew about the wound. <BR/>Record review of Resident #4's Point of Care History revealed CNA Y documented an open area to buttock on 4/1/23.<BR/>Interview on 04/21/2023 at 12:30pm, Resident #4's family member said she brought resident plant-based protein shakes, coconut water, puree oatmeal, beans, and sugar free pudding that resident would eat. The family member said Resident #4 sometimes did not like the puree food served at the NF but the food at the NF had improved. The family member said she came to the NF about three times a week and that there were other family members that came to the NF as well. The family member said when resident was admitted to the NF, he did not have any skin break down. The family member said the concerns she had with the NF was that the NF was not keeping resident clean and dry and not repositioning resident every 2 hours or as needed. The family member said over the past 2 years the family had to continuously stay on staff about assisting residents with his feeding. The family member said Resident #4 had suffered multiple strokes and could not turn himself, and therefore required total assistance with care. The family member said she was not aware of resident having any skin breakdown until 04/16/2023 around noon time. The family member said when they were assisting the CNA (name unknown) with incontinent care and had to turn resident, they observed skin breakdown to resident sacral area. The family member said she spoke with the nurse on duty who was an agency nurse. The family member said the agency nurse said she was not aware that Resident #4 had a wound to the sacral area because it was not mentioned in the shift change report. The family member said Resident #4 did not have an air mattress on his bed on 04/16/2023 and that the air mattress was just placed on resident bed a few days ago. The family member said she placed a call to the hospice nurse A who told her that the NF notice some redness. The family member said she asked the Hospice nurse how did the resident's skin breakdown go undiscovered between the Hospice company and the NF? The family member said when she observed the resident's sacrum on 04/16/2023, resident's skin was not intact and skin tissue was exposed not just redness but with bruising around the wound area. The family member said she asked the Hospice nurse why the resident was not already on an air mattress. The family member said the hospice nurse tried to say that it was the resident disease process as the reason why resident skin had break down. The family member said she told the hospice nurse that she could not accept that reason for resident skin breakdown to the sacral area.<BR/>Interview on 04/21/2023 at 12:42pm, CNA S said the first time she noticed Resident #4's skin breakdown was about 2 weeks ago or more. CNA S said at that time, resident's skin to his sacral area was a bruised purple color. CNA S said she told the nurse on duty which was an agency nurse. CNA S said it had been a lot of agency nurses working at the NF. CNA S said she was applying barrier cream to resident perineal area after administering incontinent care. CNA S said it was also about 2 weeks ago that resident's sacral area was being covered with a dressing by the nurse.<BR/>Interview on 4/21/23 at 1:00pm with CNA NN, she stated that she noticed the sacral wound and it looked like it got really bad. She said about a week ago it got bad. CNA NN was unable to provide an exact date when she noticed resident wound. CNA NN said it wasn't too deep, not like a hole, but it was open skin and red and white. CNA NN said it wasn't deep yet, the size was about a nickel size. CNA NN said she did not report it to anyone. CNA NN said, the girl (hospice aid) came to the NF and because Resident #4 was on hospice so she thought hospice would take care of it because they bathe him. CNA NN said she doesn't document it on the POC either, but she should, and she just doesn't. CNA NN said she should have reported it to the nurse. CNA NN said she would put barrier cream on it. CNA NN doesn't know the date specifically. CNA NN said she would take bandages off or they would fall off, and she didn't report it to anyone to replace the bandage. <BR/>Interview on 04/21/2023 at 1:00pm, the ADON said she started working at the NF in January of 2023. The ADON said the wound care nurse stopped working at the NF she believed April 6th, 2023. The ADON said it was the unit nurses responsibility for each hall to do the weekly skin assessments and document on the EMAR. The ADON said she just reviewed the 24-hour sheets but did not use it as a tool to communicate the resident care.<BR/>Observation and interview on 04/21/2023 at 1:50pm revealed Resident #4 resting in bed on his right side with family member at the bedside. The family member said 2 CNAs had just repositioned resident to his right side. The family member said resident refused his puree diet that the NF gave him but tolerated 30% of the chicken stock broth and almost 100% of a 32 ounce of [NAME] made with rice, milk, and cinnamon with no sediments just the juice. The family member said she tried to be creative with the resident's diet. The family member said resident now liked sweets where as before, he liked salty foods.<BR/>Observation on 04/21/2023 at 2:00pm revealed dressing change of Resident #4's sacral wound by the Unit Manager with the assistance of CNA S. Observation of the sacral wound revealed bruising (black bluish in color) surrounding the wound bed. The wound bed was a pale pink reddish in color with some sloughing (shedding of skin tissue) yellowish tissue in different sections of the wound bed. The Unit Manager cleaned the sacral wound bed with normal saline patting dry with a 4x4. The Unit Manager then applied calcium alginate followed with a dry border adhesive dressing. There was no odor detected from the wound. The nurse did not measure the wound. The wound surface area appeared to be the size of 2 silver dollar coins. There was no skin breakdown to the buttocks area. The Unit Manager said the wound appeared to be a stage II.<BR/>Interview on 04/24/2023 at 9:52am, the Hospice nurse said she started working for the Hospice Company in July of 2022. The Hospice Nurse said Resident #4 was already on hospice service and believed at one time went off and then came back on hospice services. The hospice nurse said she came to the NF once a week and as needed checking resident vital signs, doing skin assessment, assessing pain level, etc. The Hospice nurse said the NF was monitoring resident food intake. The hospice nurse said several weeks ago, the NF CNA who's name she could not remember had informed RN ZZ about Resident #4 having some skin breakdown. The hospice nurse said she could not remember the day this was reported and was driving at present time therefore could not review her documentation. The hospice nurse said Resident #4 wound was staged at a 2 and that she got an order from the NP to start treating Resident #4's wound. The hospice nurse said she also got an air mattress for Resident #4 but could not remember what day. The hospice nurse said Resident #4's intake had started to decline 3-4 months ago. The hospice nurse said about a month ago Resident #4 had begun to pocket his food. The Hospice nurse said Resident #4 had always been total care. The hospice nurse said she would not request for an air mattress unless resident had developed a wound and not before. The hospice nurse said the NF were supposed to care plan resident, keep resident turned, clean, and dry. The hospice nurse said it was expected for Resident #4 to have skin breakdown due to his health declining.<BR/>Interview on 04/24/2023 at 10:42am with the Regional Nurse and VP of Clinical Operations said the 24-hour report was used as a communication tool about the care of the resident (s) or any changes in condition. Both said the 24-hour report sheets should be used when the nurses were giving shift to shift report. Both said the DON and ADON should be reviewing the 24-hour reports daily to help guide them in their morning meeting. The VP of Clinical Operations said QAPI (Quality Assurance Performance Improvement) meetings were held once a month and as needed. The VP of Clinical Operations said topics discussed in the QAPI meetings consisted of wounds, infection control, falls, PIPS (Performance Improvement Project), etc. The Regional Nurse said typically the hospice manages the care of a resident (s) who were on their hospice services including ordering any necessary equipment that the resident may need. The Regional Nurse said she was not certain how the process worked at the NF. The Regional Nurse said the hospice nurse came to the NF once a week and the hospice CNA came to the NF 3 times a week. <BR/>Interview on 04/24/2023 at 1:48pm, the ADON said she was not aware Resident #4's total Braden Scale being a 12 with the last one at 11 signifying high risk for skin breakdown. The ADON said Resident #4 should have been placed on an air mattress. The ADON said it was herself, DON, and the wound care nurse that reviewed the residents Braden scale. The ADON said the unit nurse was the one that does the Braden scale on the residents. The ADON said had she known about resident Braden scale score, she would have ordered an air mattress. The ADON said Resident #4 could not feed himself, turn himself, and required total assistance with incontinent care. The ADON said because of resident total dependence with ADL's, on hospice care, and could not feed himself, placed resident at high risk for skin breakdown. The ADON said the previous wound care nurse should have ordered Resident #4 an air mattress. The ADON said she was new to the facility and was learning something new every day.<BR/>Attempted interview via phone on 04/24/2023 at 1:56pm and on 04/25/2023 at 1:48pm with the previous wound care nurse was unsuccessful. There was no answer and voicemail had not been set-up.<BR/>Interview on 4/26/23 at 1:00 p.m. with Resident #4's family member, she stated the hospice aid came about noon, and just left. She bathed him, she changed and shaved him. She said he had stool diaper with no dressing on it, so she went to get a nurse to dress it. Hospice aid told her she hasn't ever seen the wound it just happened last week. <BR/>Interview on 4/26/23 at 1:12 p.m. with LVN X, she stated that there was not a bandage on Resident #4's wound, but she did not know if there was a bandage on it before. She said the family member came to inform her. She said she told hospice aid as well to come get her so she can provide the daily dressing. <BR/>Interview on 4/26/23 at 1:15 p.m. with CNA R, she stated that she just changed him right before the hospice nurse came, he had two BMs. She said the wound was covered the first time, the second time the bandage was hanging off, so she took the bandage off, and she put diaper on it. She said she didn't report it to the nurse because she went straight to the dining room to pass trays. Then the hospice aid came in. She said she should report to the nurse, but she didn't get a chance to because she went straight to passing trays. <BR/>Interview on 4/26/23 at 1:24 p.m. with Regional Nurse, she stated that the ADON and DON should review the MAR together daily and the DON and ADON should review the POC notes from CNA daily as well. <BR/>Interview on 04/26/2023 at 2:50pm via phone RN ZZ said the hospice nurse came to the NF at least once a week or more to examine the residents on hospice. RN ZZ said she did not remember the exact date when the hospice nurse came to the NF, or when she worked at the NF. RN ZZ said herself and the hospice nurse went to Resident #4's room together. RN ZZ said she did not do a head-to-toe assessment but stood back and let the hospice nurse assess Resident #4 because the hospice nurse was the primary nurse for Resident #4. The surveyor asked RN ZZ if the hospice nurse assess Resident #4 skin. RN ZZ said she refused to talk to the surveyor anymore because she was not at the NF and did not feel comfortable. RN ZZ told the surveyor to talk to the hospice Nurse.<BR/>Interview on 04/27/2023 at 12:48pm, the NP said, nor he or the Doctor gave wound care orders to treat Resident #4's sacral wound. The NP said he saw Resident #4 once a month. The NP said he last saw Resident #4 on 04/26/2023 and Resident #4 was looking better compared to prior month. The NP said he was not aware of resident having a wound. The NP said any wound care orders would have come from the hospice agency or the wound care doctor or at the NF. <BR/>Further interview with the ADON 04/27/2023 at 1:27pm, she said she was new to the NF, and it had been her understanding that residents who were on hospice services, the hospice agency would assume treatment for the wound care because the NF wound care doctor did not see hospice residents. The ADON said the hospice nurse told her that she called doctor at the NF for wound care orders on Resident #4. <BR/>Interview on 04/27/2023 at 1:35pm, the doctor at the NF for Resident #4 said he did not give any orders for wound care treatment and his NP would know better if wound orders were given for Resident #4.<BR/>Further interview on 04/27/2023 at 1:40pm, the hospice nurse said she believed she got wound care orders for Resident #4 from the Medical Director of hospice. The hospice nurse said it was RN ZZ that told her that Resident #4 had skin breakdown. The hospice nurse said she told RN ZZ that she would come to the NF to assess Resident #4. The hospice nurse said she could not provide the dates of these happenings because she was driving at the time.<BR/>Interview on 04/27/2023 at 1:45pm, the Medical Director of the hospice company said he saw so many patients and could not remember Resident #4. The Medical Director said if a resident on hospice care developed a wound in the NF, hospice would collaborate with the NF wound care doctor for a treatment plan. The Medical Director said if the NF did not have a wound care doctor, he would provide orders for that resident on hospice care. <BR/>Interview on 4/27/23 at 3:35 p.m. with ADON, she stated that she was aware of the sacral wound and became aware around the 8th, when the hospice nurse was notified, but she didn't remember exact date. She stated she reviewed the MAR and reviewed it every morning. She said she looks at it and looks at what wasn't done for example, if a medication was missed. She would look at any events or orders create from the day before. She said she doesn't look at the skin assessments in the system as much as she should but she does about a once a week. She said when wound care nurse left that's when she started looking it. She said she didn't notice the 4/4 skin assessment was missing until after surveyors brought it up. She said she cannot remember going back to ask for it and cannot say that she did. She said for POC and CNA documentation, she isn't really reviewing their documentation. She pulls their reports for compliance, to make sure they were documenting, but she doesn't look at what they were documenting. They just started doing competencies checks with the CNA's, so she doesn't know who was training CNA's before on the correct documentation. The competencies for the CNA's started on Friday (4/21/23), so Monday this week she started on the 24th with competency checks. She said she would agree that the CNA's were the first ones that would notice a skin break down. She stated that the nurse should be told if there was a bandage missing, or any skin breakdown immediately. She stated the risk to resident would be infection, pain, worsening of the wound, not wanting to eat, risk of weight loss if not eating. It can take an hour for a stage 2 or stage 3 wound to develop, it would depend on the resident and their bony prominence. All three hospice residents were on different services. She said she doesn't see hospice nurse review medical records for the facility, she doesn't believe they have access. She said she doesn't review hospice records. The facility has responsibility to hospice patients even when resident was on hospice. The hospice nurse would write the orders and can work with the facility doctor. She said the hospice services would get the air mattress for the residents. She said she sees the system break down with communication between the hospice agency, agency nurses, and the facility. <BR/>Interview on 4/27/23 at 4:34 p.m. with LVN U, she said she remembered completing the skin assessment on 4/4/23. She said at the time, Resident #4 had a break down on the bottom for a while. She said she doesn't remember what she described on the report, but she said she remembered putting a bandage or patch on it. She said it was kind of a blanched and cracked area near the tip of the spine and buttocks in that area. She said it was open and kind of wrinkled a little bit. She said there was a little patch on it as well. She said she would say it was unstageable. She said the skin to the wound was beginning to open. She said there wasn't an order. She said with him being hospice she didn't know how it worked. She said she didn't tell the doctor or notify hospice. She said she believed that she did talk to Hospice Nurse, but she won't swear on the Bible about telling anyone. She said she remembered putting a patch on it for protection to help. She said the protocol was that she should have gotten an order for it and notify the doctor, but she didn't know the process for the hospice patients. She said she should have called her and told her there was break down. She said that on the 4th she had not been doing dressing changes, and it was new for her. She said she didnt' tell anyone. She said she didn't remember or know if anything was reported between the nurses. She should have spoken about it, and she knows she talked to hospice nurse, but she doesn't remember the exact day. <BR/>Interview on 04/27/2023 at 5:50pm, the VP of Clinical Services and Clinical Service Director said they realize that the NF had a lot of problems regarding the care of the residents. The VP of Clinical Services said although the NF had a lot of problems it was the responsibility of the DON and ADON to ensure nursing care were being done. The VP of Clinical Services said it was ultimately the responsibility of the Administrator to ensure that the residents were receiving adequate care.<BR/>Further interview on 04/28/2023 at 8:17am with the hospice nurse regarding the location of Resident #4's wound care orders dated 04/11/2023 of the wound being on the buttock, the surveyor asked the hospice nurse was it an error. The hospice nurse said Resident #4's wound was to his left buttock. The hospice nurse said she could go back to the NF to do another skin assessment on Resident #4.<BR/>Interview on 05/01/2023 at 10:35am, LVN X said she worked at the NF on a PRN basis. LVN X said she worked all halls including Hall 200. LVN X said she has never done any skin assessments on the residents because the wound care nurse did the skin assessments.<BR/>Interview on 05/01/2023 at 11:14am with CNA R, she said she worked full time at the NF from 6am-2pm mainly the 200-Hall. CNA R said she had provided care for Resident #4. CNA R said she remembered Resident #4 having some redness to the tailbone area and she told the nurse. CNA R was unable to provide the surveyor the first time she noticed redness to resident tailbone. CNA R said whenever she observed a change in a resident skin like redness or break in the skin, she immediately reported it to the nurse on duty but could not remember the nurse's name. CNA R said a lot of agency nurses worked at the NF. CNA said she remembered one weekend she was providing incontinent care for Resident #4 and a family member assisted with turning Resident #4 on his side. CNA R said on that day, she observed the skin on Resident #4's tailbone area open, no dressing. CNA R said she told the nurse on duty. <BR/>Record review of the NF staffing schedule on 04/16/2023 revealed that CNA R was Resident #4's CNA and RN TT (agency nurse) was Resident #4's nurse for the morning shift.<BR/>Interview on 05/01/2023 at 12:25pm, RN TT said she worked at the NF on 04/16/2023 on the morning shift. RN TT said she did not remember anything else about working at the facility and that she would have to review her documentation. RN TT said she worked at the NF one time and that was on 04/16/2023.<BR/>Interview on 05/01/2023 2:03pm, the wound care doctor said he was not aware that Resident #4 had a wound. The wound care doctor said he would have assessed and provided a treat plan for Resident #4's wound had he known. The wound care doctor said he was at the NF on 05/01/2023 and it was the first time hearing Resident #4 having a wound to the sacrum. The wound care doctor said he made wound care rounds with the Unit Manger on 05/01/2023 and the Unit Manager never mentioned resident wound.<BR/>Interview on 05/01/2023 at 2:20pm with the ADON, Unit Manager, and VP of Clinical Services said they were not aware that the wound care doctor saw wounds for hospice residents. <BR/>Record review of the NF policy on Pressure Ulcers revised 2017 revealed in apart:<BR/> .Pressure ulcers will be evaluated and treated in accordance with professional standards of practice to heal and prevent pressure ulcers .The date and onset is included in the information for the weekly wound tracking sheet and carried over week to week until healed .<BR/>Record review of the NF policy on Care Design revised 2017 revealed in part:<BR/> .The facility leadership will plan patient/resident care that will meet the level of the care required by the patient/resident/family and, community .<BR/>Record review of the NF policy on Hospice Care revised 2016 revealed in part:<BR/> .The facility retains primary responsibility for implementing those aspects of care that are not related to the duties of the hospice. It is the nursing home's responsibility to continue to furnish 24-hour room and board care, meeting the resident's personal care and nursing needs .The collaborative care plan will include skin integrity-The care plan should include, for resident who has skin integrity issues or a pressure injury or at risk of developing a pressure injury, approaches in accordance with resident choices, including, to the extent possible, attempting to improve or stabilize the skin integrity/tissue breakdown and to provide treatments if a pressure injury is present .

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide pharmaceutical services that assure accurate acquiring, dispensing, and administering of all drugs and biologicals to meet the needs of residents for each resident 1 out of 8 (Resident #3) residents reviewed for pharmacy services. in that:<BR/>-The facilityNF failed to administer Resident #3's insulin Lantus as ordered by the physician . Resident #3 did not experience actual harm.<BR/>This failure could placed Residents #3 at risk for hyperglycemia, diabetic ketoacidosis, and hospitalization.<BR/>Findings included:<BR/> Record review of Resident #3's face sheet revealed a 63year old male resident was admitted to the NF on 01/21/2022. The resident's with the following diagnoses that included Type 2 diabetes mellitus with diabetic polyneuropathy (nerve damage from pain and numbness in feet to issues with the functions of internal organs such as the heart and bladder), end stage renal disease (kidney disease), dependence on renal dialysis, absence of left leg below knee, hypertension (elevated blood pressure), and heart failure. <BR/>Record review of Resident #3's MDS dated [DATE] revealed that resident had a BIMS score of 14 indicating that resident's cognition was intact.<BR/>Record review of Resident #3's Care Plan dated 02/15/2023 revealed that resident was being care planned for risk for hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar) related to diagnosis of diabetes mellitus. Resident interventions included administer medications as ordered per MD, evaluate/record/report effectiveness/adverse side effects. Further review did not reveal that resident was being care planned for refusing his insulin. <BR/>Record review of Resident #3's Physician Orders revealed the following orders:<BR/>-dated 12/06/2022 dialysis Tuesday, Thursday, and Saturday<BR/>-dated 02/08/2023 Lantus 20 units subcutaneous (beneath the skin) for diabetes mellitus once a day at 7:00am<BR/>-dated 02/07/2023 Blood glucose checks twice a day at 7:00am and 8:00pm<BR/>-dated 04/12/2023 for a hemoglobin A1C (blood test that measures your average blood sugar levels over the past 3 months).<BR/>Record review of Resident #3's Nursing Progress Notes dated 04/10/2023 documented by LPN T revealed in part:<BR/> .Resident refused scheduled long actin insulin. PA notified. Blood sugar was 130 at breakfast time. Checked resident's blood sugar at lunch 179. Resident is in stable condition resting in bed eyes closed call light in reach. Will continue to monitor .<BR/>Further review of Resident #3's Nursing Progress Notes dated 04/11/2023 documented by LPN T revealed in part:<BR/> .Resident refused insulin due to no appetite and his scheduled dialysis day. Blood sugar 137 resident is resting eyes closed stable condition shows no s/s (signs or symptoms) of pain or discomfort will continue to monitor. Family and PA (Physician Assistant) notified . <BR/>Record review of Resident #3's MAR for January 2023 revealed on dialysis days the insulin Lantus was not administered on 8 dialysis days (01/02/23, 01/05/23, 01/14/23, 01/17/23, 01/19/23, 01/24/23, 01/26/23, and 01/28/23). Resident insulin was held on 2 non-dialysis days (01/02/23 and 01/04/23). Resident blood sugars on following days:<BR/>-01/02/23: Blood sugar at 7:00am 168, 8:00pm 163<BR/>-01/05/23: Blood sugar at 7:00am 106, 8:00pm 170<BR/>-01/14/23: Blood sugar at 7:00am 128, 8:00pm 205<BR/>-01/17/23: Blood sugar at 7:00am 97, 8:00pm 150<BR/>-01/19/23: was not documented done at 7:00am. at 8pm blood sugar 230 <BR/>-01/24/23: was not documented done at 7:00am at 8pm blood sugar 125<BR/>01/26/23: was not documented done at 7:00am at 8pm blood sugar 191<BR/>01/28/23: Blood sugar at 7:00am 129 at 8pm blood sugar 134 <BR/> Record review of Resident #3's MAR revealed for the month of February 2023 the insulin Lantus was held 4 times on dialysis days (02/02/23, 02/21/23, 02/25/23, and 02/28/23) with blood sugar ranging from 93-238. Resident insulin was held 1 time on non-dialysis day (02/24/23) resident blood sugar at 7:00am was 90 and at 8:00pm blood sugar was 224. <BR/>Record review of Resident #3's MAR for the month of March 2023 revealed that the insulin Lantus was held on 8 dialysis days (03/02/23, 03/04/23, 03/07/23, 03/09/23, 03/11/23, 03/14/23, 03/16/23, and 03/18/23), with resident blood sugars ranging from 82-289 and on non-dialysis days the insulin was held 6 days (03/01/23,03/06/23, 03/08/23, 03/12/23, 03/17/23, 03/19/23, with resident blood sugars ranging from 94-246. <BR/>Record review of Resident #3's MAR for the month of April 2023 revealed that resident did not receive insulin on 4 dialysis days (04/01/23, 04/04/23, 04/06/23, and 04/11/23) with blood sugars ranging from 120-254 and 2 non-dialysis days with blood sugar ranging from 92-234. <BR/>Interview on 04/10/2023 at 12:50pm, LPN T said she was working the 100-Hall and was Resident #3's nurse. Further interview with LPN T said Resident #3's blood sugar was 130 at 7:00am and anytime it was below 150 she would hold resident's morning insulin Lantus because she was familiar with resident's food consumption. The surveyor asked LPN T if it was the physician order to hold resident insulin Lantus? LPN T said there was not an order to hold resident insulin Lantus, she just done it that way. LPN T said she did not notify the physician about holding Resident #3's insulin and that Resident #3 and herself agreed to hold the insulin when resident blood sugar was below 130. <BR/>Interview on 04/11/2023 at 1:49pm, LPN T said on the days that Resident #3 did not receive his insulin for the month of April was because resident had refused and that she had documented. <BR/>Interview on 04/11/2023 at 2:13pm thepm, the mobile DON said that if a resident was refusing their insulin as ordered by the physician, the physician should be notified so that interventions could be put in place to better care for the resident.<BR/>Interview on 04/11/2023 at 3:05pm via phone with the NP for Resident #3, he said no one from the NF had called him regarding Resident #3 refusing his insulin on 04/10/2023 or any other day. The NP said if Resident #3 had been refusing his insulin, he would first talk to the resident educating resident on the benefits of taking his insulin before making any changes to his medications. Further interview with the NP said Resident #3 did not have PA (Physician Assistance) just himself and the doctor.<BR/>Interview on 04/12/2023 at 9:00am with the mobile DON and ADON stated confirmed that Resident #3 had a NP that came to see him and not a Physician Assistance.<BR/>Interview on 04/12/2023 at 9:20am with the RP for Resident #3 stated confirmed that they had never received a call from the NF on 04/10/23 or any other day that resident was refusing his insulin, or that resident insulin was being held on certain days. <BR/>Observation on 04/12/2023 at 9:46am Resident #3 sitting in wheelchair at the front entrance of the NF wearing street clothing. Resident #3 had a left below the knee amputation (removal of a limb). <BR/>Interview on 04/12/2023 at 9:46am, Resident #3 said he went to dialysis on Tuesday, Thursday, and Saturday. Resident #3 said he sometime refused his insulin on these days because he sometimes did not feel good but did not refuse his insulin on Monday 04/10/2023.<BR/>Interview on 04/12/2023 at 10:05am, LVN X said if a resident refused their insulin, she would notify the doctor/NP and document the happenings.<BR/>Interview on 04/12/2023 at 10:42am via phone RN U said the reason she did not administer Resident #3's morning insulin Lantus on 04/04/2023 was because resident was scheduled to go to dialysis. RN U said she was afraid resident might become hypoglycemic (low blood sugar) and therefore held resident insulin. RN U said she did not inform the doctor/NP of her holding the insulin and that it was nursing judgement.<BR/>Interview on 04/12/2023 at 11:30am, the mobile DON said she had reviewed Resident #3's MAR for 04/09/2023 and saw where resident insulin Lantus was not being administered as order by the physician. The mobile DON said she had begun to in-service the nurses on administration of insulin. The mobile DON said when insulin wasis not administered as order by the physician, resident blood sugar readings would not be consistent but up and down. The mobile DON said nurse LPN T could not come back to the NF to work and that the NF had suspended LPN T pending further investigation. The mobile DON said LPN T could not be trusted to work at the NF.<BR/>Further interview on 04/12/2023 at 11:48am, the NP said he learned from the surveyor and speaking with Resident #3 on 04/12/2023 that the insulin Lantus was not being administered as ordered. The NP said by not administering resident insulin as ordered placed resident at risk for becoming hyperglycemic (increase in blood sugar) or go into diabetic ketoacidosis (when the body does not have enough sugar to meet its energy needs, it will break down fat instead) which was not good. The NP said he would look at possibly making changes to resident insulin on dialysis days but first had to draw labs to see what resident Hemoglobin A-1 C level was. <BR/>Further interview on 04/12/2023 at 12:38pm, the mobile DON said it was herself and the ADON that monitored the resident MARs to ensure that the physician orders were being followed. The mobile DON said she had been working at the NF for 4 weeks. The mobile DON said how herself and the ADON was checking the MARS by reviewing the facility report that showed if all medications had been administered or not given. The mobile DON said she discovered that Resident #3 insulin was not being administered as ordered by the physician on 04/09/2023. The mobile DON said she began to in-service the staff regarding following physician orders and notifying the doctor when a resident (s) insulin is held or if the resident refused the medication.<BR/>Record review on 04/12/2023 of in-service done with the NF staff on insulin medication administration documentation, 5 rights of medication administration, and when a resident refuses to take insulin the doctor and RP must always be notified, dated 04/10/2023. <BR/>Record review of physician orders for residents on dialysis revealed that Resident #3 was the only resident that received insulin.<BR/>Interview on 04/13/2023 at 1:55pm, the ADON said the NF ran a facility report on the MARS each morning and it was reviewed by herself and the DON. The ADON said if a resident refused their insulin, the unit nurse should be calling the physician to notify that resident refused their insulin. The ADON said she had to be honest that due to her being pulled in so many directions and the only ADON, she had not had time to review the facility report and follow-up with the nurses to ensure that physician orders were being carried out. The ADON said LPN W was and Agency nurse. The ADON said she did not know if the NF had in-serviced agency staff on notifying the physician if a resident refused their insulin or if the insulin had to be held. The ADON said she was never involved in any in-services or training with agency staff. <BR/>Interview on 04/13/2023 at 2:50pm, RN V said she worked at the NF PRN. RN V said she remembered caring for Resident #3. RN V said if the medication insulin was held, she documented that she notified the doctor via text or phone. The surveyor informed RN V that the surveyor was unable to locate in the Nursing Progress Notes that Resident #3's physician or NP had been notified of insulin refusal or that the insulin was held until 04/10/2023 by LPN T. LPN T did not respond after the surveyor informed her of this. <BR/>Further interview on 04/13/2023 at 4:35pm with the NP said he had reviewed Resident #3 blood sugars and resident blood sugars were good overall. The NP said he had ordered a hemoglobin A1C 3 days ago and was waiting on the results. <BR/>Record review of Resident #3's Hemoglobin A1C labs revealed the following:<BR/>-dated 04/16/2023 reading 6.3 (normal range 4.5-5.7)<BR/>-dated 11/20/2022 reading 6.0<BR/>-dated 06/27/2022 reading 5.1 <BR/>Interview on 04/17/2023 at 1:05pm, the Regional Nurse and mobile DON said it was the responsibility of the DON to ensure that staff was being trained and in-serviced on when to notify the physician of any changes regarding the residents medical care including refusal of medications or if a medication his held. The mobile DON said she could not locate the staff training/in-service binder for the NF. The DON said the NF had not had a steady DON for a while. <BR/>Attempted interview on 04/17/2023 at 1:45pm via phone with LPN W regarding Resident #3's insulin not being administered as ordered, no answer, left voicemail with a call back number.<BR/>Interview on 04/17/2023 at 1:50pm via phone LPN W said she was an agency nurse that had been coming to work at the NF for about 2 months on a prn basis (as needed). LPN W said she had not received any in-service on when to notifying the physician regarding medications. LPN W said she did not remember Resident #3. LPN W said if she held insulin Lantus, it was a nursing judgement call and that she did not call the doctor every time she held insulin. <BR/>Interview on 04/19/2023 at 10:30am, the mobile DON and the Regional Nurse said the NF did not have a policy on insulin administration. The surveyor asked the mobile DON and Regional Nurse for the NF policy on management of medication administration for dialysis residents. The Regional nurse said she would have to look and see if the NF had such a policy. The mobile DON said Resident #3 was the only dialysis resident that had an order for insulin. The mobile DON said she had done in-service on blood glucose monitoring check off list with the staff and in the following weeks she would be ensuring that all staff had their competencies check off list done. The DON said she would be doing a QAPI (Quality Assurance Performance Improvement) and PIP (Performance Improvement Project) on insulin administration. <BR/>Interview on 04/19/2023 at 10:48am, the Doctor for Resident #3 said he and his NP were the only medical health care providers that gave orders on Resident #3 at the NF. The doctor said he learned from his NP that the Nursing staff at the NF werewas not administering resident's insulin Lantus as ordered. The doctor said a conversation needed to be had with him and the NF regarding resident refusing medication Lantus, that he could look at other alternatives involving resident medication.<BR/>Interview on 04/19/2023 at 11:08 am, the Pharmacist said she came to the NF each month and that she was coming to the NF on 04/20/2023 to do the NF Drug Regimen Review. The Pharmacist said she had been working at the NF for 6 months and that the NF had 4 DON's working at the NF in that time frame. The Pharmacist said she reviewed Resident #3's medications on last month and did not make any recommendations. The Pharmacist said she did not review the residents MARS because she did not have access to the MARS therefore did not know that the nursing staff was not administering resident insulin as ordered by the physician. The Pharmacist said the nursing staff should not have been holding Resident #3's Lantus unless they had parameters given by a physician. The Pharmacist said it would have been okay to administer the insulin on dialysis days. The Pharmacist said if she had known that Resident #3 was refusing his insulin-on-dialysis days, she would have made a recommendation to the doctor to administer the insulin in the evenings after dialysis that way resident could still receive the insulin. The Pharmacist said when the insulin wasis not administered as order, the blood sugar level could rise damaging the kidneys further and Resident #3 was already on dialysis. <BR/>Record review of the NF Policy on Medication Management Program revised 2017 revealed in part:<BR/> .The facility implements a Medication Management program to meet the pharmaceutical needs of patients and residents, according to established standards of practice and regulatory requirements .The facility will collaborate with the Medical Director and the attending physician on the application of the drug formulary and therapeutic change . <BR/>Record review of the NF Policy on documentation-Licensed Nursing pertaining to the patient/resident will be recorded with regulatory requirements revised in 2017 revealed in part:<BR/> .If a scheduled medication is withheld or not give as ordered, the nurse documents this and list the reason for the patient/resident not receiving the medication. The attending physician or physician extender must be notified. Route must be charted .

Based on interview, record review and observation, the facility failed to ensure each resident was provided with a nourishing, palatable, well-balanced diet that met his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident for 59 of 61 residents that receive food from the kitchen.<BR/>1.The facility failed to have an effective system in place to ensure sufficient and routine replenishment of food for all residents.<BR/>2.The facility failed to have a trained Dietary manager on staff to supervise staff, ensure sanitary work environment and ensure balanced meals were being provided to residents at assigned mealtimes.<BR/>3.The facility failed to provide approved and adequate substitutions.<BR/>4.The facility failed to have an effective system in place to ensure food was properly stored and that expired or spoiled food items were discarded. <BR/>This failure had the potential to affect all facility residents who consumed food from the facility's kitchen.<BR/>The findings included: <BR/>Observation of the kitchen inventory of food supplies on 4/8/23 beginning at 11:08am revealed: The food supply on hand was only sufficient for one lunch or dinner meal to feed the entire census (59 residents eat food from the kitchen) based on the amount per serving of available food items: The facility has a 10 lbs. chuck roast which could serve 50 residents giving them 3 oz of protein. They also had 7 and 1/2 quarts of mix scrambled eggs, which would feed 50 residents. For produce, the facility had tomatoes that were rotten, spinach that was slimy and rotten. They had some parsley.<BR/>Observation of the refrigerator in the main kitchen area on 4/8/2023 beginning at 11:08am revealed the following:<BR/>A container of eggs, with a used by date of 4/7/23. Unlabeled, undated container of what appears to be peaches. Unlabeled, undated container of what appears to be macaroni and cheese. Unlabeled, undated, open container of what appears to be sliced meat. Unlabeled, undated open sliced cheese. Unlabeled, undated box of chicken with liquid residue spilling onto refrigerator. Undated open carton of scrambled eggs. <BR/>Interview with [NAME] D on 4/8/2023 at 11:15am, he stated he did not have the food available to cook that was on the menu for today. He stated that he would substitute spaghetti, but he does not have the ground meat. He stated he does not know what he will cook and was trying to figure it out. He stated the substitution items also were not available. He stated that he was not the one who orders food supply for the kitchen. He said the previous dietary manager who no longer works at the facility was responsible for ordering the food. He stated the administrator was now the person that orders the food. He stated that they do not have produce, as the produce they do have was molded. He stated the administrator was made aware they needed food on 4/7/2023 and she told him she would work on it. He stated food should be labeled and dated so that they do not serve food that was not edible or within the use by date. <BR/>Observation of lunch being served on 4/8/2023 revealed lunch service began at 1:40pm and the last trays for lunch was served 2:24 pm. 6 to 7 residents received grilled cheese. <BR/>Record review and observations for lunch and dinner on 4/8/2023, revealed the items on the menu was not served. Lunch menu for 4/8/23 revealed teriyaki chicken, fluffy rice, seasoned mixed vegetables, fresh baked roll, frosted cake. Lunch menu served to residents on 4/8/2023 was sliced pork, mashed potatoes, and cauliflower. Some residents observed eating grilled cheese sandwiches at lunch. Undated dinner menu revealed hot roast beef sandwich, baked potato, broccoli & cauliflower, gelatin cubes with whip topping. Dinner menu served to residents revealed chopped ham mixed with corn, beans, and cauliflower. <BR/>Observation on 4/9/23 at 2:00pm of the refrigerator in the main kitchen area near the steam table revealed a box of molded rotten tomatoes, 1 bag of parsley, 5 bags of spinach with black liquid.<BR/>Observation of lunch being served on 4/9/2023 revealed lunch service began at 1:30pm and the last trays for lunch was served at 2:25pm. <BR/>Record Review of Mealtimes posted in the dinning room of the facility revealed Breakfast is between 7-8am, Lunch 12pm and dinner 5pm. <BR/>Record review and observations for lunch and dinner on 4/9/2023, revealed the menu item was not served. Lunch menu for 4/9/23 revealed red beans, rice & sausage, seasoned greens, fresh baked roll, cinnamon baked apples. Lunch menu served to residents revealed fries and sliced sausage. Dinner menu dated 4/9/23 revealed Turkey club sandwich macaroni salad, pickled beets, frosted chocolate cake. Dinner menu served to residents revealed chuck roast and beans. <BR/>Observation of lunch being served on 4/10/2023 revealed lunch service began at 2:30 p.m.<BR/>Interview with Resident #2 on 4/8/2023 at 1:48pm, he stated he has been waiting for 45 minutes for lunch. He stated he was very hungry and asked a dietary aide whose name he can't remember when food will be ready. He stated he was told it would be soon, but he has been waiting a long time. <BR/>Interview with Resident #5 on 4/8/2023 at 1:55pm, she stated she has been waiting for food and she was hungry. She stated the facility needs to hire more dietary aides and cooks because residents were hungry and have been waiting a long time. <BR/>Interview with Resident #6 on 4/8/2023 at 1:56pm, she stated she has been waiting 1hr and 30 mins for lunch. She stated breakfast was a long time ago and she was starving. <BR/>Interview with Resident #7 on 4/8/2023 at 2:02pm, she stated she came to the dining area around 11:30am. She stated the staff normally start serving lunch between 12pm and 12:30pm. She stated there was no snack other than the vending machine because when she goes to the kitchen, they are busy or shorthanded and no one comes to the door. She stated there was no snacks at the nursing station. <BR/>Interview with Resident #10 on 4/8/2023 at 2:08pm, she stated she had not been served lunch and that she was still waiting. She stated she was hungry. <BR/>Observation on 4/8/2023 at 2:09pm Resident #4, observed still awaiting lunch.<BR/>Interview with Resident #8 on 4/8/2023 at 2:15pm, she stated that she was hungry and waiting on lunch. <BR/>Interview with Resident #9 on 4/8/2023 at 2:25pm, she stated she had been waiting for 2 hours for lunch and was offered a grilled cheese sandwich. She stated she asked for ham and there wasn't any ham left. <BR/>Observation and interview on 4/8/2023 at 2:28pm with Resident #7 she stated the staff ran out of food and gave me a grilled cheese sandwich. Observation revealed a half-eaten grill cheese sandwich on the plate in front of Resident #7.<BR/>Observation of the kitchen on 4/8/2023 at 2:20pm during lunch revealed the food serving trays were empty and the administrator was preparing grilled cheese sandwiches.<BR/>Interview at 4/8/2023 at 2:21pm with Administrator she stated [NAME] D abandoned his shift and she was now the cook and the administrator. She stated she had her food handler's certificate. She stated she was making grilled cheese sandwiches because residents requested it. When asked if there were any other food options for residents, she stated the residents requested grill cheese.<BR/>Interview on 4/9/2023 at 11:45am with [NAME] C he stated he did not know what he was cooking that day and that he did not have the food supply to cook what was on the menu for that day. He states he contacted the Administrator, and she told him to find a substitute. He stated the person responsible for ordering food was the dietary manager who no longer works at the facility. He stated that the administrator was responsible for ordering food and that the last time he worked was 4/7/2023 and he told the administrator on 04/07/2023 that they needed food supplies.<BR/>Interview on 4/9/2023 at .with Dietary Aide A, she stated she last worked on 4/7/2023 and she informed the administrator that the kitchen needed juice and snacks for the residents. She said the administrator told her she would handle it. She stated that she came back to work today 4/9/2023 and there was not enough food supplies and still no juice or snacks ordered from her request that was made on 4/7/2023. <BR/>Observation of the steam table on 4/10/23 at what time before lunch service revealed green peas at 25 degrees, chopped pork at 99 degrees, pureed peas at 125 degrees, pureed meat at 120 degrees.<BR/>In interview with RVP on 4/11/2023 at 12:00pm, she stated the administrator oversees the facility, and the kitchen as much as she can. She did not review the sanitation report but had received it via email. She has not been in the kitchen, only to the door. She reported it's between the dietician and the administrator when they review the sanitation report, they discuss how they would solve the issue. She can' not confirm what the issues were March 2023 regarding the sanitation report. She stated Administrator oversees the overall operation of the facility. Stated she does not expect to be told everything that was going on in the building as that was not her role, she was the consultant. She said the administrator was the top of the chain at the facility, and she does not overstep her position. She stated she believed the facility was running well but based in this interview she would agree the system the administrator was using was not working.<BR/>In an interview with the Dietician on 4/11/2023 at 12:45pm, she stated that the administrator contacted her on 4/9/2023 about substituting menu for hotdog on a bun and peaches. She stated the administrator did not inform her of the menu that was supposed to be served. The Dietician stated she instructed her to substitute bread for bread, protein for protein, starch for starch and fruit and vegetable for fruit and vegetable. She stated residents consuming food that is expired and have no use by date, can have an increased risk of being sick. The Dietician stated there was a list for approved substitutions and was represented by replacing protein for protein, vegetable for vegetable, bread for bread, starch for starch and fruit for fruit. The Dietician stated the approval for 4/9/2023 was not represented in the meal served. She stated without the appropriate substitution, residents can be at risk of not getting the appropriate amount of protein and caloric nutrition, which can lead to weight lost. <BR/>In an interview with Administrator on 4/11/2023 at 2:00pm, she stated a Dietary manager has been hired but has not started. Stated the facility has been without a dietary manager since the beginning of March 2023. She stated on Thursday 4/6/2023 she did rounds in the kitchen and observed the cleanliness, food storage and did not take inventory. She stated on 4/6/2023 the kitchen was clean, and all items were labeled and dated. She stated human resources did rounds on Friday 4/7/2023 in the kitchen as well ensuring it was clean and food items were stored correctly. She stated she would expect the kitchen to get dirty during service and cleaned daily. She stated that she did not keep a log of her kitchen audits because it was not a regulation. She stated that her audits are by pop ins and the area she audits varies. She stated she reviewed the sanitation report with the dietician and corrected all the issues. She stated she did go a little low on emergency food supply and she ordered more food on 4/10/2023. She stated the kitchen currently has adequate shelving. She stated she cleaned off the can opener because it was a little dirty and did not purchase a new one. She stated if the kitchen was unsanitary, it can pose a risk to residents due to cross contamination. She stated certain meat if not kept at the right temperature can cause residents to get sick. She stated that food not dated or labeled can cause the kitchen staff to not be able to tell how long it can be used. She stated she could not answer whether everything was dated, labeled and in accordance with professional standards of food service because she had not been back there today. She stated if dishes are not being sanitized correctly it could cause the dishes to be cross contaminated. <BR/>In an interview with Medical Director on 4/11/23 at 3:00pm, he stated he was not informed of food issues and diet substitutions at the facility.<BR/>Record review of the facility's undated nutritional policy revealed that resident's will be served liberalized diets that a resident would eat at home, unless otherwise indicated by Physician/registered dietician nutritionist assessment. The policy also revealed that meals will be served at consistent times daily with controlled portions. The key points of the policy revealed that the facility should:<BR/>o Meet nutrition needs and enhance quality of life.<BR/>o Identify the resident's nutrition care preferences/choices.<BR/>o Optimize meal intake and increase satisfaction with meals.<BR/>o Promote enjoyment and consumption of meals to prevent unintended weight loss and under nutrition.<BR/>Record Review of the facility's undated nutrition policies related to purchasing reflected:<BR/>- a system is in place to identify items needed, based on the menu, from the grocery, bread, dairy, and produce vendors. No salesperson is permitted to inventory and order food or supplies for the facility.<BR/>- Check in each order as it is delivered, making certain that items are delivered as ordered and are not damaged.<BR/>- Order and receive non-food supply according to need from supply inventory sheet in the same manner as food orders.

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

Based on observation, interview and record review, the facility failed to prepare food by methods that conserve nutritive value, flavor, and appearance to 8 residents who received a pureed diet in that. <BR/>The facility failed to follow the recipe for pureed menu items.<BR/>The facility failed that foods were prepared by methods that conserved nutritive value and flavor.<BR/>These failures could affect all residents who received pureed meals by placing them at risk of weight loss, altered nutritional status and diminished quality of life. <BR/>Findings included:<BR/>Observation on 04/10/2023 at 1:45pm during lunch preparation of pureed menu items revealed [NAME] C preparing the pureed diet for the lunch meal. [NAME] C took some chopped pork put it in the food processor and added water and blend it. For the peas he used the #12 scoop which is equivalent to 2 and 3/4 ounces and put it in the food processor and add some water and blend it, for the potatoes he put the potatoes in the food processor and blend it. [NAME] C did not peel the potatoes he blended it with skin, and he did not measure any of the menu items. [NAME] C did not use a recipe.<BR/>Record review of the of the undated recipe for Pureed Potatoes revealed 1 portion of potato place in food processor and add juice from meat until desired pudding like consistency was reached.<BR/>Puree should be smooth texture, no lumps, liquid must separate from solid, may not be sticky. Shows some very slow movement under gravity, but cannot be poured, hold shape on spoon & fall off spoon in a spoonful. <BR/>In an interview on 4/10/2023 at 1:55 p.m. with [NAME] C he said he did not have a recipe to follow for the pureed food. He said he was preparing pureed meals for 8 residents. He said he used water as liquid. It was explained that she did not measure the portion size of the menu items or the liquid. At that point he did not say anything. He said he was not trained to prepare pureed menu items.<BR/>Observation on 4/12/2023 at 12:30pm revealed [NAME] C preparing pureed meat. He put the meat in the food processor went to the juice machine and got some juice and was about to pore the juice on the chicken. At that point the Surveyor intervened and asked what kind of juice he had, and he said it was lemonade. At that point he made some broth and blend the chicken.<BR/>Interview with [NAME] C on 4/12/2023 at 12:45pm regarding the use of lemonade to puree the chicken he said he eats everything. Asked what should be used to puree the meat he did not answer. <BR/>Record review of the undated pureed recipe for baked potato for 10 residents<BR/>Potatoes, [NAME] 10 each<BR/>Ground Pork 1 3/8 lbs.<BR/> Cheese Cheddar grated 5/8 lbs.<BR/>Sour Cream 5/8 cups.<BR/>Puree: Smooth texture, no lumps, liquid must separate from solid, may not be sticky. Shows some very slow movement under gravity, but cannot be poured, hold shape on spoon & fall off spoon in a spoonful. <BR/>Record review of undated Seasoned [NAME] Peas for 10 <BR/>Peas, green frozen 1 3/4 lbs.<BR/>Pepper black &frac14; Tsp<BR/>Salt 5/8 Tsp<BR/>Margarine 0.05lbs.<BR/>1. <BR/>Place peas in pot. Cover with minimum amount of boiling water. Simmer about 5 minutes until tender. Do not overcook.<BR/>2. <BR/>Pureed Instructions: (Portion size=#8 dipper) Measure &frac12; cup cooked peas and 1 TBSP water for each serving needed into food processor. Blend until smooth. Pour into baking pan, cover, and reheat to 165 degrees before serving. Discard any leftover product at the end of meal service.<BR/>Notes:<BR/>1. <BR/>4Pureed:<BR/>Smooth texture. No lumps, liquid must not separate from solid, may not be sticky. Shows some very slow movement under gravity, but cannot be poured, hold shape on spoon & fall off spoon in a single spoonful.<BR/>In an interview on 4/11/2023 at 12:55pm with Dietitian she said that the staff were in-serviced on pureed diet when she was last in the facility. She said some of the kitchen staff were new and she was not sure if they were in serviced. She said she said that she was going to in-service them again.<BR/>Observation of Test Tray done on 4/14/2022 at 1:50pm revealed the following:<BR/>Pureed carrots had no flavor it was bland, Pureed Lasagna was very spicey (hot from black pepper).<BR/>Chicken had no flavor (bland). The meal did not look appetizing it had all the same color. <BR/>In an interview with the Dietary Manager on 4/14/2023 at 1:55pm she said the lasagna was very spicy/peppery, the carrots and chicken had no flavor. She said she was going to have the staff in-service on the use of black pepper and ensure the menu items had flavor and the colors were not the same. Regarding the color she said she told one of the tray aides, the colors were the same when the tray line was set up. <BR/>Observation and interview on 4/21/2023 beginning at 12:20pm of lunch revealed [NAME] E serving lunch, [NAME] E took a plate put some pureed vegetables, pureed meat, and pureed bread on the plate. He then put regular Twice Baked Potato Casserole on the plate. At that point the Surveyor asked what modified diet he was serving, and he said it was a pureed diet. Asked at that point if that was pureed Twice Baked Potato Casserole and he did not answer. Further observation revealed no pureed starch on the steam table. [NAME] E then took some Twice Baked Potato Casserole and put it in a pan pour some water from the faucet and pour it on the Twice Baked Potato Casserole, put it in the food processor and blend it. He did not measure the ingredients.<BR/>In an interview on 4/21/2023 at 12:40pm [NAME] E was asked if he was trained on pureed diet he said No. The Surveyor at that point asked if he had tasted the pureed potato for flavor, he said it had flavor because the regular Baked Potato Casserole had flavor. At that point he was asked to take the temperature of the pureed baked potato casserole and it was 96.7 degrees F. He then took the pureed potato off the steam table and reheat it to 165 degrees F.<BR/>Record review of Ingredients for baked potato casserole <BR/>Bacon 1/10 pounds bacon<BR/>Potato pearls dry &frac12; pounds<BR/>Cold water 3 5/8 cups<BR/>Dry Mince onion 1 &frac14; Tsp<BR/>Sour Cream 3/8 cups<BR/>Shredded Cheddar Cheese 1/8 pound <BR/>5. Puree & Mechanical Soft Instructions: Portion size is &frac12; cup. Measure &frac12; cup prepared casserole for each serving needed into food processor. Blend until smooth. Pour into greased pan, cover, and reheat to 165 degrees F or higher. Discard any product left at the end of meal service, do not reheat.<BR/>Notes:<BR/>1. <BR/>For Pureed: Measure desired # of servings into food processor. Blend until smooth. Add liquid if product needs thinning. Add commercial thickener if needs thinning. Add commercial thickener if product needs thickening. <BR/>2. <BR/>For Pureed:<BR/> Smooth texture. No lumps, Liquid must not separate from, may not be sticky. Shows some very slow movement under gravity, but cannot be poured, hold shape on spoon & fall off spoon in a single spoonful.<BR/>Record review of the monthly audit dated 3/28/2023 revealed that the kitchen staff was in-service on food storage/dry food storage, storage in refrigerator and freezer, dish machine, kitchen sanitization.<BR/>Record review of the Nutritional Policies and Procedures date 8/1/2020 read in part .<BR/>Subject: Food Preparation:<BR/>Policy: <BR/>Food will be prepared and attractively served using methods that conserve nutritive value, flavor, and appearance.<BR/>5. Batch cook vegetables to conserve nutrient value and maintain flavor and color.<BR/>6. Prepare altered consistency foods such as ground, chopped and puree foods to meet the patient's/resident's individual needs and satisfaction. The facility will use the international Dysphagia Diet Standardization Initiative (IDDS) as the foundation for texture modified foods and thickened drinks provided to residents.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in the only facility kitchen.<BR/>The facility steam tray water reservoir and glass covering, were dirty.<BR/>The facility failed to clean the floor of the walk- in dry storage room.<BR/>The facility failed to change the grease in the deep fryer.<BR/>The deep fryer, overhead hood of the stove, stovetop, and burners were dirty. <BR/>The facility failed to repair the drainage system for 2 drains in the kitchen cooking, preparatory and meal service areas. <BR/>These failures could place the residents who ate meals prepared in the kitchen at risk for food borne illness.<BR/>Findings included:<BR/>During observations on 2/19/23 at 11:55 a.m., the grease in the deep fryer was dark brown with food debris. The sides of the deep fryer were dirty with black and white streaks down the sides. The overhead hood had globules of brown grease hanging from the brim of the metal hood. The stove cook top was dirty with crumbs and dark grease build up on each eye of the 6- burner stove, as well as the metal backsplash of the stove. There was 1 grey singed oven mitt on the metal overhang above the stove. The floor drain in front of the stove range and the deep fryer had an oatmeal type substance bubbling out of it and surrounding the metal corrugated top of the drain. There were small black gnats flying around it. There was a second drain near the food prep area that had the same oatmeal like material surrounding the drain that appeared dried. Continued observation of walk-in dry storage room with black streaks, skid marks and footprints observed all over the floor. There was only 1 kitchen staff member who was preparing the lunch time meal service and the last steam tray water reservoir to the right, was a turbid brown with a white residue floating on top of it, like a film. The glass to the steam table was cloudy, streaks, spots, speckles, and a hazy film covering the glass. <BR/>During an interview on 2/19/23 at 12:15 p.m., with an anonymous staff A who said the oil in the deep fryer needed to be changed. They said it had not been done because they had been working all morning alone. They said that the entire kitchen needed to be cleaned and that the night FSS were responsible for cleaning the deep fryer, stove and basically everything that was dirty including the floors in the walk-in dry storage room, the sides of the deep fryer and stove hood as well as the burners on the stove. They said that the 2 drains had been backing up for at least 2 weeks and that the administrator had been aware because it was repeatedly reported to her by several staff including the old DM and MD. They said that several staff had quit within the last few weeks, and that the administrator said she would fix things, but things never got fixed. They said they did not know why or how the oven mitt on the top of the metal overhang of the stove got burned or singed and said they had not used them that day and did not know when they had been laundered last. They said the steam table should have been cleaned by the evening/night FSS and did not know when the steam tray or glass had been cleaned.<BR/>During an interview and observation of facility kitchen with Administrator and FSS on 2/19/23 at 1:44 p.m., When the Administrator was shown the dark brown grease in the deep fryer and the food debris, she shook her head. When asked if it needed to be cleaned and the grease changed, she shook her head yes. When shown the brown globules of grease hanging from the brim of the metal hood over the soiled and dirty stove and backsplash and the bubbling drain in front of the deep fryer and stove, she said that on 2/16/23 the maintenance assistant fixed the drainage/plumbing issue and that 2/16/23 was the first time she heard anything about the issue. She said that she had been in the kitchen on 2/17/23 and did not see any drainage or residue on the floor or residue on the floor around the drains or any backflow from the floor drains. When asked if the deep fryer, stove, metal backsplash, steam table tray, vent hood, walk- in dry storage floor and overall kitchen appearance was the same, she did not answer the question. When asked if the kitchen was in the same condition on 2/17/23 as it was on 2/19/23 she did not reply. The Administrator said that the DM quit on 2/7/23 and that the former Maintenance Director's last day was 2/10/23. She said that the evening/night FSS were responsible for cleaning the kitchen and had a cleaning schedule they were to follow. The Administrator said that the kitchen and all the items observed should have been cleaned and the grease in the deep fryer changed. The Administrator said the kitchen needed to be cleaned. She said that the DM was responsible for ensuring that the kitchen was cleaned and that if there were no DM, she would be ultimately responsible of ensuring that it was done. The Administrator did not know when the last deep cleaning or cleaning schedule had been completed. Surveyor requested a copy of completed deep cleaning and or cleaning schedules that had been documented as completed by FSS, from the Administrator at that time and did not receive them prior to exit. <BR/>Interview and observation with FSS B, on 2/19/23 at 1:46 p.m., who was unsure how long the 2 drains had been backing up onto the kitchen floor but said that the former Maintenance Director had tried to fix the issue before he stopped working at the facility. FSS B said that only 2 of 4 drains were affected and only when they ran water in the kitchen in the preparatory sink or ran the dish machine. FSS B said that the evening/night FSS were responsible for cleaning the kitchen and did not know why there had been no one completing the cleaning as scheduled or ensuring that someone else completed the cleaning per the schedules.<BR/>Record review of an incomplete, undated The [NAME] Deep Clean Schedule provided by Administrator on 2/19/23 at 1:44 p.m., read as follows: PM Sunday-Fryer (drained, completely cleaned, replace oil, scrub the whole thing inside and outside clean with degreaser) .PM Monday-Stove/Oven (burners to be taken off and cleaned, shelf and backsplash clean and wipe with degreaser, doors and sides clean and wipe with degreaser, inside oven scrubbed clean, oil drip tray scrubbed clean with degreaser) .PM Wednesday-Scrub floor (scrub floor form backsplash to steamtable, from reach in to coffee station) .AM Saturday- Steamtable (around wells need to be scrubbed clean, on top of shelf and under shelf needs to be scrubbed clean, sides and where knobs are need to be scrubbed and cleaned, pull everything out from bottom shelf and needs to be scrubbed and cleaned with degreaser.<BR/>Record review of undated Nutrition Orientation & Competency Policies And Procedures provided by Administrator on 2/19/23 at 1:44 p.m., read in part: FLOORS .There is usually an established routine for cleaning the floors in the food areas. It is important to maintain this routine to assure a clean Nutrition/Culinary Services Department. The routine usually includes sweeping several times a day and mopping at least once a day.<BR/>Record review of The Food and Drug Administration Codes October 2015, 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils indicated:<BR/> . (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch. <BR/>(B) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. <BR/>(C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue and other debris .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to be administered in a manner that enables it to use its resources effectively to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, staff, and visitors for (59 of 61 residents) residing in the facility and having meals prepared from the only kitchen, and for the staff and residents in the building during gas leak. <BR/>The Administrator failed to immediately take action when staff and residents reported a smell of gas in the facility for 3 days. <BR/>The facility administration failed to ensure sufficient and replenished food supply for residents, proper storage, preparation, distribution and serving of food in accordance with professional standards of food safety in the absence of a Dietary Manager.<BR/>The facility administration failed to ensure the kitchen was a sanitary work environment.<BR/>The facility administration failed to have an effective system in place to ensure sufficient and routine replenishment of food for all residents.<BR/>The facility administration failed to have a trained Dietary manager on staff to supervise staff, ensure sanitary work environment and ensure balanced meals were being provided to residents at assigned mealtimes.<BR/>The facility administration failed to provide approved and adequate substitutions.<BR/>The facility administration failed to have an effective system in place to ensure food was properly stored and that expired or spoiled food items were discarded.<BR/>An Immediate Jeopardy (IJ) was identified on 4/6/2023 at 5:58 p.m. While the IJ was removed on 4/11/2023 at 4:13 p.m., the facility remained out of compliance at the severity level of actual harm that is not immediate jeopardy, and a scope of pattern while the facility continued to monitor the implementation of effectiveness of their plan of removal.<BR/>A second Immediate Jeopardy (IJ) situation was determined to have existed on 04/12/2023 at 10:38am. While the IJ was removed on 04/25/2023 at 5:26PM, the facility remained out of compliance at actual harm with the potential for more than minimal harm that is not immediate jeopardy and a scope of a pattern due to the facility's needs to evaluate the effectiveness of the corrective systems<BR/>These failures placed all residents, staff, and visitors at risk of getting sick due to prolonged exposure to gas fumes and/or carbon monoxide and at risk of food borne illness. <BR/>Findings include:<BR/>Record review of public record request # PIR-2023-706 on 4/10/23, revealed that Incident # 23002345 stated the FD was dispatched to the facility due to a 911 call concerning smell of gas inside. Fire Chief B was the reporter. It read in part on March 26, 2023, E16 dispatched emergency traffic for smell of smoke or gas. upon arrival to scene to a single-story nursing home nothing was showing, and investigation commenced. once inside we were directed to the end of the 100 hall. Halfway down the hallway CO readings began to read 31 ppm. The reading continued to be reading between 18 and 30ppm in the end corridor. nursing staff was instructed to move residence out of Hall 100. All rooms and halls were investigated with 5 gas monitoring. Boiler room was noticed to have furnace that when turned on readings reached 700ppm of CO. (31ppm and 700 ppm indicates how many parts of carbon dioxide there is in one million parts of air). Maintenance was informed of this leak and gas supply was then turned off. maintenance informed us that plumbers would fix the leak tomorrow.<BR/>the 100 hall was then ventilated until CO readings consistently maintained O ppm. End of call. Further review of the incident report revealed that there were four firemen on the scene. They were at the facility from 17:13:47(5:13 p.m.) to 18:39:01 (6:39 p.m.). <BR/>Observation of the Fire Department Body camera dated 3/26/23 revealed: <BR/>17:25 (5:25 p.m.) Body cam #3: entered front door of facility, asked staff about kitchen, or any gas hook ups. Staff reported not knowing anything about the building.<BR/>17:25 (5:25 p.m.)- entered 100 hall. A staff stated to FD they had to raise a resident's window (this was near the end of hall, room [ROOM NUMBER] seen on video)<BR/>17:26 (5:26 p.m.) Resident on hall in wheelchair traveling down hall, heard FD stated reading of CO at 30 ppm. Then stated a big spike in the reading over there on the CO (the FD is at the back on 100 hall near therapy door)<BR/>17: 33 (5:33 p.m.) observed staff go into room [ROOM NUMBER] to assist resident <BR/>17:35 (5:35 p.m.) Observed resident in wheelchair on hall 100 near 106 <BR/>17:46 (5:46 p.m.) heard a resident on 200 hall tell FD yesterday the gas smell was strong<BR/>17:49 (5:49 p.m.) staff ask FD if fire truck was in the front, he said yes, she was seen on her phone<BR/>17: 49 (5:49 p.m.) FD states maintenance said this happened about a week ago<BR/>17: 49 (5:49 p.m.) FD explained to staff they are getting readings of high CO levels but can't find where it is coming from. Staff heard on phone reporting to somewhere that there are high CO levels.<BR/>17:50 (5:50 p.m.) staff telling staff let's move residents<BR/>17:52 (5:52 p.m.)- 3 staff standing on 100 hall, not moving residents<BR/>17:53 (5:53 p.m.) staff comes to FD and states: I don't know what's going on, the administrator does not want to admit that there is high CO in the building do you want to talk to her? FD responded I don't care what she admits to. Staff dials a number and gives phone to FD- he said he was with FD, and he says one of your nurses said you might want to talk to me. He says to the person on the phone that they told staff to clear out the hall where they are getting CO reading and, clearing out the hallway was an immediate thing. <BR/>17:56 (5:56 p.m.) confirmed with staff that administrator was told to clear out that hallway, explains to staff that if they cannot find the leak and isolate the leak then they cannot let them stay operating and would have to shut the building down. Explained if fire started over here (100 hall) it could impact the other side of building. <BR/>18:06 (6:06 p.m.) FD says its strong reading going up and up 50 to 55, to 75. <BR/>18:07 (6:07 p.m.) shut off valve to gas line and started opening windows and doors. FD upset the maintenance saying that had a gas leak a week ago and didn't say anything. <BR/>18:09 (6:09 p.m.) FD stated every time that thing (referring to the furnace or hot water heater) would kick on they would have the CO emitted. Says probably been going on a while. Staff requested name and phone number in case she gets terminated. FD explained to her she was doing what they asked her to do. <BR/>18:12 (6:12 p.m.) FD moved outside stating it wasn't good to be standing around it.<BR/>18:19 (6:19 p.m.)- staff approached FD and asked about moving residents. FD stated it was recommended to move the patients. Staff Requested FD to call administrator, FD stated he already called her. Staff stated that she (person on the phone) told one of the nurses to not move the patients. FD said to tell her the other option is to have ambulances come and move all the patients. Explained they could get CO poisoning. <BR/>18:20 (6:20 p.m.) resident seen on 100 hall and FD told resident to go the other way. FD explained to nurses what carbon monoxide poisoning is. A Nurse told another nurse to call ADON- he said he got off phone with the assistant and he was told that the assistant said to keep the residents in the room. FD was saying it was very serious. And it wasn't up to the nurse, it was FD decision. Nurse called the administrator, administrator did not answer, and she left a message. FD told them to move residents again. FD said administrator texted and said she was driving; she didn't answer the phone. <BR/>18:23 (6:23 p.m.) staff started moving residents. FD stated that he already talked to the lady to move residents about 30 minutes ago. FD says it smells terrible almost like it had been leaking for a year. <BR/>18:35 (6:35 p.m.) FD explained to staff that they killed the gas. End of video<BR/>An interview was conducted with Fire Chief A of the local fire department (FD) on 4/4/2023 at 9:24 a.m., revealed him to state that A shift responded to an anonymous 911 call from Solidago Nursing and Rehab on 3/26/23. He stated that they found the area near the lobby/nursing station had a carbon monoxide reading of 35 parts per million (PPM) on their 5-gas monitoring device which samples air and is used to detect oxygen (O2), carbon monoxide (CO), hydrogen sulfide (H2S ppm) and volatile organic compounds (VOC ppm) and low explosives level (LEL). He said that they must always do an air sample when there is complaint of a gas smell. As they moved further down Hall 100 and entered the boiler room located at the back of the building (where Halls 100 and 500 intersect), they found that the reading was 700 parts per million of carbon monoxide. Chief C informed RN V that they needed to evacuate the residents from Hall 100. He said that Chief C talked to the Administrator and maintenance director and when he noticed that staff were not moving residents off the hall, he announced that he would shut the whole building down. He stated that they decided to shut the main gas line down because natural gas not burning properly created the carbon monoxide. So, cutting the gas supply would eliminate any carbon monoxide because even a small amount of carbon monoxide can be harmful to the residents. He said they opened doors and allowed the carbon monoxide to dissipate before they left the facility. FD recommended that the facility contact a certified plumber. FD stated some symptoms of carbon monoxide poisoning included dizziness, headaches, shortness of breath, and loss of consciousness. <BR/>An interview was conducted with LVN U on 3/28/2023 at 3:25pm, she stated that she worked on 3/26/23. She said that someone from Solidago called the fire department anonymously to report the gas smell. She said that she did smell gas in the building on or about 3/24/23 when she returned from being off on 3/23/23. She said that she checked with the residents down Hall 100 and most said that they could not smell gas. She said that Resident #2 mentioned that he could smell gas and she heard from other staff (unwilling to provide names) that they had been smelling gas for about 1 week. She said that she did not report it to the Administrator. She said, they knew it smelled like gas. She said that (they) were the Administrator and ADON. She did not explain how they knew about the gas smell.<BR/>An interview was conducted with the maintenance director on 3/28/23 at 3:45p.m., he said that staff reported that they could smell gas near 100 hall on or about 3/23/23. He said that he put soap and water on all the valves (process called soaping the joint) near Halls 100 and 500. He said that he did not find a leak. He said if there was a leak the soap would bubble. He stated that this is a skill he was taught through previous work experience. He stated that it was reported to the Administrator during their morning meeting on or about 3/24/23. He said that the Administrator as well as Therapy Director, BOM, SW, Wound Care nurse and ADON were present for the meeting. He stated that the therapy director was the first person to inform him of the gas smell. He said that the plumber came out on 3/27/23 but did not have the part to repair the gas valves on the furnace and hot water heater. He said that the FD turned the gas line off on 3/26/23. The plumber returned on today (3/28/23) and replaced the valves on the furnace and the hot water heater. <BR/>Observation rounds on 3/28/23 at 3:50 p.m., revealed a closet located at the back of the building near Halls 100 and 500 had a hot water heater and a furnace. The gas smell was strong. <BR/>An interview was conducted with the Administrator on 3/28/2023 at 4:12pm, she stated that RN V text her on 3/26/23 and said that there was a gas smell in the facility and the fire department had been called. She stated this is when she first learned that there was a gas leak and that they found carbon monoxide. She said that it was reported to her that the fire department had found a small gas leak. She said from what she understands, the alarm would have been triggered if there was over 50 parts per million of carbon monoxide in the building. She said that she did not believe that the small leak was harmful. She said the problem was resolved within an hour. She stated that carbon monoxide poisoning could cause headache, sleepiness, nausea and if super high could cause death. She confirmed that she was present for the morning meetings the week of 3/20-3/24/23 but denied anyone mentioning a gas leak. She informed me that she take the notes for their morning meetings.She stated she didn't smell any gas odors during the week of 3/20-3/24/23. She stated the FD did not tell her to evacuate the residents. According to her, she informed her corporate RVP and VP of Clinical Services Director and was advised to follow directives of the fire department, keep them informed and take the residents vitals. She stated that the DON, ADON are charge in her absence and any emergencies are supposed to be handled by the maintenance director.<BR/>An interview was conducted with Resident # 9 on 3/29/23 at 10:28am, revealed her to state that the Administrator was aware of the gas smell, and she did not do anything about it. She said that they had been smelling gas for about 1 week and nothing was done until the fire department was called on 3/26/23. She said that she had all her faculties and that she told the Administrator that she could smell gas on or about 3/21/23. She said that the Administrator is not telling the truth about the gas leak. She said the Administrator should have called the gas company. She said that the Administrator told her and others that the smell was coming from some flooring on Hall 500, but she did not believe her. She said that the Administrator was not trustworthy and did not care about the residents. Resident #9 resided on Hall 100.<BR/>Record review of Resident #9 MDS dated [DATE] revealed C0500. BIMS summary score was 15. <BR/>An interview was conducted with CNA N on 3/29/23 at 10:48 a.m., revealed that she was off a few days during the week of 3/20-3/24/23 but believe she returned to work on 3/24 or 3/25/23 and could smell gas. She said she called the ADON on 3/25 around 9:30 a.m. on the on-call phone to inform her that she could smell gas. She said the ADON told her she would call Administrator and let her know, but maintenance was aware of the problem. She said that she had a headache and was feeling sleepy on 3/25/23. She said that someone called 911 and the fire department told RN V that they found high levels of carbon monoxide in the building. She said there is no freedom to voice concerns in the building, but she did report the gas smell to ADON. She said she made the ADON aware of it on Saturday 3/25/23, but ADON and Administrator allowed another day to go by without doing anything.<BR/>An interview was conducted with CNA Q on 3/29/23at10:50 a.m., stated that she was ill from the gas fumes. She said they wanted the fire department to come because they were worried about the residents. She said that the CNA's cares more about the residents than the Administrator does. She said that she works Hall 200 mostly but she also helps with Hall 100. She said that there was a gas smell in that area (Halls 100 and 500) for over a week. She said that she was having headaches and nausea from the gas smell. She said staff would talk amongst themselves, but they were afraid to call and get help. <BR/>An interview was conducted with RN V on 4/3/23 at 2:49 p.m., she stated that the fire department came while on her 6a-6pm shift on 3/26/23. She said that upon their arrival she immediately text the ADON (per chain of command). She said that there were approximately 4 or 5 on the fire team. She said that they began to walk throughout and around the outside of building checking for carbon monoxide. She said she was informed by a member of the FD that the carbon monoxide levels were high in the room where the puzzles were located (at the end of 100 and 500 halls) and boiler room. She said that the ADON said that she let both the Administrator and Maintenance Director know that the fire department was there due to the gas leak. At first, she said that the Administrator told her that the fire department was not there because she had checked the cameras. She said that she took a picture of the fire truck on her cell phone and text it to her. She said that she allowed Chief C to communicate with the Administrator from her cell phone. She said that she started soliciting help to evacuate the residents, getting them dressed and helping transfer them to their wheelchairs, because the FD told her that she needed to evacuate the residents from Hall 100. She said this is what Chief C told her to do. She said when she got back on the phone, the Administrator said that she was told that the levels were low and there was no need to evacuate the residents. She said that it was obvious that the FD felt they were not moving the residents fast enough, because Chief C announced that he would shut the whole building down if they did not start moving the residents. She said she text the Administrator again because she wanted to make sure she was okay with them moving the residents. She said that the Administrator responded, You were already moving them RN V. She said there was a lot of commotion because it was also time for change of shift. She said one fireman was observed coming from the outside and another from the back of the building. She said that only a few residents had been evacuated to the front lobby when she was informed that the fire department was going to shut down the gas line. The residents were taken back to their rooms. She was told that they were airing out the building and had propped open the back door for air to circulate. <BR/>In an interview with Fire Chief A of the local fire department (FD) on 4/4/2023 at 9:24a.m. revealed that A shift responded to an anonymous 911 call from the facility on 3/26/23. He stated that they found the area near the lobby/nursing station had a carbon monoxide reading of 35 parts per million (PPM) on their gas monitoring device which samples air and is used to detect oxygen (O2), carbon monoxide (CO), hydrogen sulfide (H2S ppm) and volatile organic compounds (VOC ppm). He said that they must always do an air sample when there is complaint of a gas smell. As they moved further down Hall 100 and entered the boiler room located at the back of the building (where Halls 100 and 500 intersect), they found that the reading was 700 parts per million of carbon monoxide. Chief C informed RN V that they needed to evacuate the residents from Hall 100. He said that Chief C talked to the Administrator and maintenance director and when he noticed that staff were not moving residents off the hall, he announced that he would shut the whole building down. He stated that they decided to shut the main gas line down because natural gas not burning properly created the carbon monoxide. So, cutting the gas supply would eliminate any carbon monoxide because even a small amount of carbon monoxide can be harmful to the residents. He said they opened doors and allowed the carbon monoxide to dissipate before they left the facility. FD recommended that the facility contact a certified plumber. FD stated some symptoms of carbon monoxide poisoning included dizziness, headaches, shortness of breath, and loss of consciousness<BR/>An interview was conducted with Therapy Director on 4/4/23 at 10:45 a.m., revealed that a gas odor was strong between 3/22/23-3/26/23 as the therapy room is in the corner of Hall 500 (where the highest concentration of carbon monoxide was found). She reported the gas odor to the Maintenance Director on or about 3/22/23. He said that he would investigate it. She said that she kept the door to therapy closed. She said that the maintenance director talked about the gas leak multiple days in the morning meeting. She said that she mentioned it in the meeting too because the smell was strong. She said the maintenance director said he was working on it. She recalls the Administrator, ADON, SW, BOM, WCN and maintenance director being present for those meetings during the week of March 20-24, 2023.<BR/>Record review of resident #1 face sheet revealed he was a [AGE] year-old male who was diagnosed with chronic obstructive pulmonary disease (COPD-a condition involving constriction of the airways and difficulty or discomfort in breathing) heart failure, cellulitis (a bacterial skin infection), muscle weakness, chronic pain, polyneuropathy (malfunction of many peripheral nerves through the body), chronic atrial fibrillation( an irregular and often rapid heart rhythm and mood disturbance and anxiety. He resided on Hall 100.<BR/>Record review of Resident #1 MDS dated [DATE], section C0500. BIM summary score was 15.<BR/>An interview was conducted with Resident # 1 on 4/4/23 at 11:15 a.m., he said that it was difficult for him to breath due to the strong gas odor on or about 3/25/23. He described the smell as a heater furnace just being turned on for the first time in the winter. He said that a nurse (later known as RN V) came to open his window to allow a flow of air. He was later moved to the lobby. He utilizes an oxygen concentrator. He said he told the nurse that he was having difficulty breathing earlier in the day on 3/26/23. He did not specify which nurse. He says multiple different staff came to his room. But, it was not the same nurse that opened his window. He said that the night nurse took his vitals. <BR/>Record review of resident # 2 face sheet revealed that he was a [AGE] year-old male who is diagnosed with unspecified dementia, muscle weakness, abnormalities of gait and mobility, generalized arthritis, insomnia, post-traumatic stress disorder (PTSD). He resided on Hall 100. <BR/>Record review of Resident # 2 MDS dated [DATE], revealed section C0500 BIM summary score was 8. <BR/>An interview was conducted with Resident #2 on 4/4/23 at 11:26 a.m., he said that he experienced fast heartbeat and was light-headed on or about 3/26/23. He said LVN U asked him if he could smell gas earlier in the week and he said that he did not smell anything at that time. But, on 3/26/23 he could smell gas and was light-headed. He said he does not usually feel that way. Resident # 2 resided on Hall 100.<BR/>An interview was conducted with the ADON on 4/4/23 at 11:31am, she said that she was informed of the gas leak during morning meeting on 3/24/23, if she can recall correctly. She denied smelling gas. She said the maintenance director announced that he was trying to resolve the problem. She said she received a text from staff on 3/26/23 stating they could smell gas. She said she immediately informed the Administrator via text message. She said she was told that the maintenance director was working on fixing the problem. <BR/>An interview was conducted on 4/5/23 at 10:42 a.m. with Texas master licensed plumber, with plumbing company. Stated he was completing another job for the facility related to draining and an employee said that they had an issue with gas. He stated he used a gauge test with air after shutting off the gas to check the pressure and the gauge was dropping slowly at 10psi. He stated it was letting air go through which would mean there is a leak. He replaced the valves on the meter on which had the central heating and water heater because it was where the leak was found. He called the gas natural gas. He did not check for carbon monoxide. He does not normally check for carbon monoxide.<BR/>Record review of a letter from plumbing company, dated April 10th, 2023, revealed that they were working at facility on March 27 doing some repairs to sewer line, same day that a facility staff personnel asked technicians to check on a smell of gas in the mechanical room. Technicians proceed to test the gas line with 10 PSI of air for 15 minutes and pressure dropped very slow, indicating that there was a leak in line. Technician turned gas off until parts were ordered, and service could be completed. The technicians ordered new valves for the water heater and furnace and returned to the facility the following day March 28 to replace valve and perform another test at 10 PSI for another 15 minutes and pressure held indicating there was no more leaks at this unit. There is no mention of Carbon Monoxide check.<BR/>A group interview ensued with Chief A, Chief C and attempted interview with Chief B on 4/6/2023 at 10:30 a.m.,<BR/>Chief A stated that they found carbon monoxide at the facility. <BR/>Chief B -was dispatched just before the interview started.<BR/>Chief A stated that he arrived about 15 minutes after the team arrived to assist. <BR/>Chief C stated that he spoke with the Administrator and Maintenance on 3/27/23. He told the Administrator that the carbon monoxide was found in the building and numbers were highest in the back of the building near Halls 100 and 500. At that time, he stated that they needed to evacuate the residents down Hall 100. He said that the Administrator was pushing back. She said that maintenance told her that the levels were 13/19 ppms. He said he was the person that talked to maintenance, and he never told him that. He said the carbon monoxide numbers were not as high in the front of building or outside, but they were at 700ppms in the boiler room. He said that he handed the phone to RN V and when he did not observe them moving the residents, he announced at the front nursing station he would shut the whole building down. By that he said he would have called ambulances to transport the residents to a nearby hospital because any amount of carbon monoxide can be hazardous to people who are already ill. He said that he has never dealt with an administrator that would not follow his orders. He said the nurse handed her phone to him maybe twice, he felt like the Administrator was giving the nurse pushback too. <BR/>A subsequent interview was conducted with ADON on 4/6/2023 at 12:44pm, she stated that it was on Thursday in stand-up, maintenance director said that a plumber was coming. She said that she made a mistake on the date of the stand-up meeting because she worked on Thursday night (3/23), so she was not in the morning meeting on 3/24. It was on 3/23/2023, if she recalls correctly. She said that the Maintenance director only said that he had a plumber coming. She said that they knew there was a boiler issue on Hall 500. The managers talk all day long, so she is not sure when the boiler issue first came up. She said that she first learned that it was gas leak when she received a text by RN V on Sunday (March 26th). <BR/>RN V text her at 3:55pm, Hey the gas leak is a concern do we have a Co2 detector?. She said she asked her what is a co detector?. She notified the Administrator immediately via text. She said that the Administrator was driving but said she would call maintenance. She said RN V said she was concerned that it was carbon monoxide poisoning. She said that she told RN V, Maintenance and Administrator are aware and that they were in communication, if it was carbon monoxide the alarm would have gone off. She said she never talked to the fireman, she said that was something that Administrator needed to talk to them about. She said she talked to RN BB and he said fire department wanted them to evacuate the residents. Then, RN BB told her that the FD said don't move the residents because the carbon monoxide was so low that they did not have to move the residents. She said that she was going to head to the facility, but RR BB told her to hang tight, he didn't think he needed her to come because the fireman was coming back to him to report. She stated at 6:23p.m., RN BB text and said that fire chief wants everyone off Hall 100. Minutes later he said no need to evacuate because the fireman said the gas was being turned off. She denied that anyone reported or informed her that they smelled gas in the facility. She said the risk of carbon monoxide depends on the levels of gas exposure, headache, altered mental status the risk of gas or carbon monoxide exposure. She stated, If she was the Administrator, she would have immediately called the fire department or have maintenance shut the gas down. She stated that Resident # 13's family member reported the gas smell to her on March 26, 2023. <BR/>A subsequent interview was conducted with maintenance director on 4/6/23 at 1:14pm, he said this is how he recalls the week of March 20-26, 2023:<BR/>Thursday - (3/23)- report of gas smell from therapy director and an unnamed nurse. He stated that he went by the Administrator's office and reported it to her. He said both himself and his assistant worked on soaping the joints to try to find a leak on both Thursday and Friday. He said that they sprayed gas lines in 5 mechanical rooms. No leak found.<BR/>Saturday (3/25)- came to the facility to soap more of the lines. No leak found.<BR/>Sunday (3/26)- call from RN V said FD was there and wanted to speak with him. He said that he is not sure of the FD personnel that he spoke with, but he did say that they found carbon monoxide. He said he is not sure what amount. But high because he said that they were going to evacuate the residents. Then, he was told that the FD was just going to cut the gas line supply off and that he would need to get a plumber to fix the valves.<BR/>An interview was conducted with BOM on 4/6/23 at 2:00 p.m., he stated that he recalls maintenance director informing them in morning meeting during the week of 3/20-3/24/23 about a gas leak. He stated that he attended morning meetings every day that week. He said that he recalls the Administration, Wound care nurse, Therapy Director, maintenance, and ADON in these meetings. <BR/>An interview was conducted with Med Aide A on 4/6/23 at 2:32 p.m., she stated she had headaches and the stated that the gas smell started on or about 3/21/23, she was told it was not gas. That they were working on flooring down Hall 500. She said therapy was complaining about the smell too. She said her normal shift consisted of passing medication on Halls 100 and 200. She said that called in to work on 3/24/23 because she was not feeling well. She had a bad headache and nausea.<BR/>A subsequent interview was conducted with the Administrator on 4/6/2023 at 2:51 p.m., she stated that she was not informed by maintenance nor any other personnel that there was a gas smell in the building. She first learned about the gas leak/carbon monoxide on 3/26/23. She denied the fire department staff told her to evacuate the residents. She said that it was RN V that wanted to move them, so she asked to speak to Chief C. She said that the risk of being exposed to carbon monoxide above 50ppms could cause headaches. She said that the carbon monoxide was low otherwise the alarm panel would have alarmed, according to her understanding of the fire panel at Solidago. She said that Occupational Safety and Health Administration (OSHA) standards says 50ppm of carbon monoxide is not hazardous. She did not provide any literature for OSHA Therefore, she did not see the harm. She did not call in an incident report to Health and Human Services for this reason.<BR/>Review of the facility's activity report dated 3/26/2023, revealed that Resident #13 family came to visit. They were concerned about the smell of gas. RN V said that she would report it to administration. Resident #13 was not interview able. He resided on Hall 100. <BR/>Record review of the facility census dated March 29, 2023, revealed that Resident #13 resided on Hall 100 close to the end of the hall where Hall 500 intersects.<BR/>An interview was conducted on 4/10/2023 at 12:57pm, the former Wound Care Nurse stated in morning meeting on approximately 3/20/23 or 3/21/23, therapy director reported that there was a strong smell of gas. She told the administrator that she had been smelling gas for a while. The Administrator stated that the 500 unit used to be on a separate gas line. That is why they could be smelling gas. He said multiple days it was bought up in the morning meeting. He said he felt like he was walking uphill for over a week. He[TRUNCATED]

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

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in the only facility kitchen.<BR/>The facility steam tray water reservoir and glass covering, were dirty.<BR/>The facility failed to clean the floor of the walk- in dry storage room.<BR/>The facility failed to change the grease in the deep fryer.<BR/>The deep fryer, overhead hood of the stove, stovetop, and burners were dirty. <BR/>The facility failed to repair the drainage system for 2 drains in the kitchen cooking, preparatory and meal service areas. <BR/>These failures could place the residents who ate meals prepared in the kitchen at risk for food borne illness.<BR/>Findings included:<BR/>During observations on 2/19/23 at 11:55 a.m., the grease in the deep fryer was dark brown with food debris. The sides of the deep fryer were dirty with black and white streaks down the sides. The overhead hood had globules of brown grease hanging from the brim of the metal hood. The stove cook top was dirty with crumbs and dark grease build up on each eye of the 6- burner stove, as well as the metal backsplash of the stove. There was 1 grey singed oven mitt on the metal overhang above the stove. The floor drain in front of the stove range and the deep fryer had an oatmeal type substance bubbling out of it and surrounding the metal corrugated top of the drain. There were small black gnats flying around it. There was a second drain near the food prep area that had the same oatmeal like material surrounding the drain that appeared dried. Continued observation of walk-in dry storage room with black streaks, skid marks and footprints observed all over the floor. There was only 1 kitchen staff member who was preparing the lunch time meal service and the last steam tray water reservoir to the right, was a turbid brown with a white residue floating on top of it, like a film. The glass to the steam table was cloudy, streaks, spots, speckles, and a hazy film covering the glass. <BR/>During an interview on 2/19/23 at 12:15 p.m., with an anonymous staff A who said the oil in the deep fryer needed to be changed. They said it had not been done because they had been working all morning alone. They said that the entire kitchen needed to be cleaned and that the night FSS were responsible for cleaning the deep fryer, stove and basically everything that was dirty including the floors in the walk-in dry storage room, the sides of the deep fryer and stove hood as well as the burners on the stove. They said that the 2 drains had been backing up for at least 2 weeks and that the administrator had been aware because it was repeatedly reported to her by several staff including the old DM and MD. They said that several staff had quit within the last few weeks, and that the administrator said she would fix things, but things never got fixed. They said they did not know why or how the oven mitt on the top of the metal overhang of the stove got burned or singed and said they had not used them that day and did not know when they had been laundered last. They said the steam table should have been cleaned by the evening/night FSS and did not know when the steam tray or glass had been cleaned.<BR/>During an interview and observation of facility kitchen with Administrator and FSS on 2/19/23 at 1:44 p.m., When the Administrator was shown the dark brown grease in the deep fryer and the food debris, she shook her head. When asked if it needed to be cleaned and the grease changed, she shook her head yes. When shown the brown globules of grease hanging from the brim of the metal hood over the soiled and dirty stove and backsplash and the bubbling drain in front of the deep fryer and stove, she said that on 2/16/23 the maintenance assistant fixed the drainage/plumbing issue and that 2/16/23 was the first time she heard anything about the issue. She said that she had been in the kitchen on 2/17/23 and did not see any drainage or residue on the floor or residue on the floor around the drains or any backflow from the floor drains. When asked if the deep fryer, stove, metal backsplash, steam table tray, vent hood, walk- in dry storage floor and overall kitchen appearance was the same, she did not answer the question. When asked if the kitchen was in the same condition on 2/17/23 as it was on 2/19/23 she did not reply. The Administrator said that the DM quit on 2/7/23 and that the former Maintenance Director's last day was 2/10/23. She said that the evening/night FSS were responsible for cleaning the kitchen and had a cleaning schedule they were to follow. The Administrator said that the kitchen and all the items observed should have been cleaned and the grease in the deep fryer changed. The Administrator said the kitchen needed to be cleaned. She said that the DM was responsible for ensuring that the kitchen was cleaned and that if there were no DM, she would be ultimately responsible of ensuring that it was done. The Administrator did not know when the last deep cleaning or cleaning schedule had been completed. Surveyor requested a copy of completed deep cleaning and or cleaning schedules that had been documented as completed by FSS, from the Administrator at that time and did not receive them prior to exit. <BR/>Interview and observation with FSS B, on 2/19/23 at 1:46 p.m., who was unsure how long the 2 drains had been backing up onto the kitchen floor but said that the former Maintenance Director had tried to fix the issue before he stopped working at the facility. FSS B said that only 2 of 4 drains were affected and only when they ran water in the kitchen in the preparatory sink or ran the dish machine. FSS B said that the evening/night FSS were responsible for cleaning the kitchen and did not know why there had been no one completing the cleaning as scheduled or ensuring that someone else completed the cleaning per the schedules.<BR/>Record review of an incomplete, undated The [NAME] Deep Clean Schedule provided by Administrator on 2/19/23 at 1:44 p.m., read as follows: PM Sunday-Fryer (drained, completely cleaned, replace oil, scrub the whole thing inside and outside clean with degreaser) .PM Monday-Stove/Oven (burners to be taken off and cleaned, shelf and backsplash clean and wipe with degreaser, doors and sides clean and wipe with degreaser, inside oven scrubbed clean, oil drip tray scrubbed clean with degreaser) .PM Wednesday-Scrub floor (scrub floor form backsplash to steamtable, from reach in to coffee station) .AM Saturday- Steamtable (around wells need to be scrubbed clean, on top of shelf and under shelf needs to be scrubbed clean, sides and where knobs are need to be scrubbed and cleaned, pull everything out from bottom shelf and needs to be scrubbed and cleaned with degreaser.<BR/>Record review of undated Nutrition Orientation & Competency Policies And Procedures provided by Administrator on 2/19/23 at 1:44 p.m., read in part: FLOORS .There is usually an established routine for cleaning the floors in the food areas. It is important to maintain this routine to assure a clean Nutrition/Culinary Services Department. The routine usually includes sweeping several times a day and mopping at least once a day.<BR/>Record review of The Food and Drug Administration Codes October 2015, 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils indicated:<BR/> . (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch. <BR/>(B) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. <BR/>(C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue and other debris .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide an ongoing program of activities designed to meet the interests and the physical, mental, and psychosocial well-being of 4 of 4 residents reviewed for activities.<BR/>At the confidential group interview residents stated there were no organized activities most days and never on weekends.<BR/>This failure could place residents who could attend activities at risk of boredom, depression, and a decreased quality of life.<BR/>Findings include: <BR/>Interview 09/28/2022 at 10:00 AM Resident Counsel Meeting. Basically, residents have no activities in the facility. Activities are whatever residents arrange on their own to do. Activities consist of bingo once or twice a week and this only began 2 weeks ago. Before then, the facility was not offering anything for the residents to do. Residents had learned to entertain themselves since there are no activities.<BR/>Interview 09/29/22 at 10:40 AM SC stated she works Monday thru Friday from 8:30 AM to 5:00 PM and does not work weekends. SC assists RA with activities since the facility does not have an AD at this time. SC stated at 11:00 AM 09/29/22, her and RA are doing Bingo in the dining room. RA usually tries to do activities twice a day. SC was unaware who if anyone did activities on the weekends.<BR/>Interview 09/29/22 at 11:00 AM RA stated she works Monday thru Friday from 8:00 AM to 5:00 PM and does not work weekends. RA stated she had been covering activities for the last 30 days since the previous AD resigned at that time. RA stated she tried to hold activities twice a day in the dining room. RA stated that there is an activities schedule for September 2022 created by the AD before she resigned. The AD is responsible for creating and following the activities schedule. RA stated in addition to covering activities, RA is responsible for covering central supplies and restorative care with residents. As such, RA stated it is difficult for her to follow the activities schedule. Therefore, she allows residents to determine the activity the enjoy most to ensure participation. RA stated she goes from room to room asking residents their preferred activity. When the majority agree on the activity RA and the other staff again go from room to room informing residents of the time of the activity and encouraging all to participate. RA stated she does not know if the facility holds activities on the weekends. RA stated she goes room to room painting female resident's nails and reading or playing eBooks for the male residents who cannot physically get to the dining room for activities. RA is presently reading a [NAME] to Resident #52. RA stated she does not document her activities interactions with residents and did not have an answer as to why not. She stated at this time she has not offered any other activities to residents that cannot get to the dining area. She stated there are several activities that the residents can do such as bingo, puzzles, coloring books, and painting. RA also offers residents root beer floats, popcorn socials, and the monthly birthday cake to celebrate resident's birthdays each month. RA stated that she did not create the September 2022 activities schedule. RA stated that the are no activities calendars for the coming months. RA stated AD resigned without notice. RA also stated that the AD either destroyed or took all the activities records with her because there were activities documentation prior to AD resigning and once AD left, the activities documents were unlocatable. <BR/>Interview 09/29/22 at 12:21 PM Administrator stated AD's last day with the facility was 08/01/22. Administrator was trying to rehire for the AD position. The facility was not following the Activities Schedule at this time. The activities scheduled notes at the bottom subject to change. There was no activities log since the AD resigned. The facility holds several activities: movies at night., coloring and bingo. Today, 09/29/22, the facility will be having birthday cake and ice cream to celebrate residents born in September. On the weekends, all staff assist in activities for the residents. Coloring pages, activities books and puzzles are left at the nurse's station to be passed out to residents interested in activities. Residents on the 300 hall really enjoy the coloring pages. Up until 09/26/22, MDS worked Saturdays and Sundays and headed activities. MDS now works Monday through Friday and every other weekend. MDS will continue activities on her weekend shifts and CNAs will assist MDS and oversee on the weekends that MDS is not scheduled to work. There is no activities log of residents who participated in activities. The AD was responsible for the resident council meeting minutes and the activities calendar. Administrator stated when AD quit, AD was disgruntled and the resident council meeting minutes, activity calendars, activity log, grievance log and grievances went missing. Administrator stated there is no activities policy. <BR/>Interview 09/29/22 at 12:37 PM MDS stated she was scheduled on weekends until 09/26/22 when she was promoted to MDS. Since, 09/26/22, MDS stated she works throughout the week with one or two days off and every other weekend. MDS stated when she works the weekend, she is the weekend's supervising charge nurse and does the activities with the residents. She stated the residents enjoy various activities such as ice cream socials, playing old movies on the big tv in the dining room, playing music and dancing/exercising and or moving in their chairs. She stated residents prefer to have bingo every day. She stated residents have expressed that they enjoy bingo the most. She stated if residents could create the activities schedule that is all the residents would prefer to do. MDS stated she also goes room to room visiting with residents who cannot get up and gather for activities. MDS stated she takes those residents newspapers, coloring material and shares her Lego fish tank made by her 9-year-old son. She stated the residents enjoy the bright colors of the Lego fish tank <BR/>Observation on 09/27/22 at 10:35 AM no football pictures activities in dining room per activities schedule. Television was playing a daytime talk show and 6 residents were sitting by themselves at tables. The resident were not doing any activities and there were no staff present.<BR/>Observation on 09/27/22 at 11:30 AM no lunch time trivia in the dining room per activities schedule. Television was playing a daytime talk show and 6 residents were sitting by themselves at tables.<BR/>Observation on 09/27/22 at 02:45 PM no football bingo in dining room per activities schedule. Television was playing a movie and 3 residents were sitting by themselves at tables.<BR/>Record review of the Activity Calendar for the month of September 2022. Activities scheduled for every day in the month of September 2022 to include Monday through Friday and Saturday and Sunday.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in the only facility kitchen.<BR/>The facility steam tray water reservoir and glass covering, were dirty.<BR/>The facility failed to clean the floor of the walk- in dry storage room.<BR/>The facility failed to change the grease in the deep fryer.<BR/>The deep fryer, overhead hood of the stove, stovetop, and burners were dirty. <BR/>The facility failed to repair the drainage system for 2 drains in the kitchen cooking, preparatory and meal service areas. <BR/>These failures could place the residents who ate meals prepared in the kitchen at risk for food borne illness.<BR/>Findings included:<BR/>During observations on 2/19/23 at 11:55 a.m., the grease in the deep fryer was dark brown with food debris. The sides of the deep fryer were dirty with black and white streaks down the sides. The overhead hood had globules of brown grease hanging from the brim of the metal hood. The stove cook top was dirty with crumbs and dark grease build up on each eye of the 6- burner stove, as well as the metal backsplash of the stove. There was 1 grey singed oven mitt on the metal overhang above the stove. The floor drain in front of the stove range and the deep fryer had an oatmeal type substance bubbling out of it and surrounding the metal corrugated top of the drain. There were small black gnats flying around it. There was a second drain near the food prep area that had the same oatmeal like material surrounding the drain that appeared dried. Continued observation of walk-in dry storage room with black streaks, skid marks and footprints observed all over the floor. There was only 1 kitchen staff member who was preparing the lunch time meal service and the last steam tray water reservoir to the right, was a turbid brown with a white residue floating on top of it, like a film. The glass to the steam table was cloudy, streaks, spots, speckles, and a hazy film covering the glass. <BR/>During an interview on 2/19/23 at 12:15 p.m., with an anonymous staff A who said the oil in the deep fryer needed to be changed. They said it had not been done because they had been working all morning alone. They said that the entire kitchen needed to be cleaned and that the night FSS were responsible for cleaning the deep fryer, stove and basically everything that was dirty including the floors in the walk-in dry storage room, the sides of the deep fryer and stove hood as well as the burners on the stove. They said that the 2 drains had been backing up for at least 2 weeks and that the administrator had been aware because it was repeatedly reported to her by several staff including the old DM and MD. They said that several staff had quit within the last few weeks, and that the administrator said she would fix things, but things never got fixed. They said they did not know why or how the oven mitt on the top of the metal overhang of the stove got burned or singed and said they had not used them that day and did not know when they had been laundered last. They said the steam table should have been cleaned by the evening/night FSS and did not know when the steam tray or glass had been cleaned.<BR/>During an interview and observation of facility kitchen with Administrator and FSS on 2/19/23 at 1:44 p.m., When the Administrator was shown the dark brown grease in the deep fryer and the food debris, she shook her head. When asked if it needed to be cleaned and the grease changed, she shook her head yes. When shown the brown globules of grease hanging from the brim of the metal hood over the soiled and dirty stove and backsplash and the bubbling drain in front of the deep fryer and stove, she said that on 2/16/23 the maintenance assistant fixed the drainage/plumbing issue and that 2/16/23 was the first time she heard anything about the issue. She said that she had been in the kitchen on 2/17/23 and did not see any drainage or residue on the floor or residue on the floor around the drains or any backflow from the floor drains. When asked if the deep fryer, stove, metal backsplash, steam table tray, vent hood, walk- in dry storage floor and overall kitchen appearance was the same, she did not answer the question. When asked if the kitchen was in the same condition on 2/17/23 as it was on 2/19/23 she did not reply. The Administrator said that the DM quit on 2/7/23 and that the former Maintenance Director's last day was 2/10/23. She said that the evening/night FSS were responsible for cleaning the kitchen and had a cleaning schedule they were to follow. The Administrator said that the kitchen and all the items observed should have been cleaned and the grease in the deep fryer changed. The Administrator said the kitchen needed to be cleaned. She said that the DM was responsible for ensuring that the kitchen was cleaned and that if there were no DM, she would be ultimately responsible of ensuring that it was done. The Administrator did not know when the last deep cleaning or cleaning schedule had been completed. Surveyor requested a copy of completed deep cleaning and or cleaning schedules that had been documented as completed by FSS, from the Administrator at that time and did not receive them prior to exit. <BR/>Interview and observation with FSS B, on 2/19/23 at 1:46 p.m., who was unsure how long the 2 drains had been backing up onto the kitchen floor but said that the former Maintenance Director had tried to fix the issue before he stopped working at the facility. FSS B said that only 2 of 4 drains were affected and only when they ran water in the kitchen in the preparatory sink or ran the dish machine. FSS B said that the evening/night FSS were responsible for cleaning the kitchen and did not know why there had been no one completing the cleaning as scheduled or ensuring that someone else completed the cleaning per the schedules.<BR/>Record review of an incomplete, undated The [NAME] Deep Clean Schedule provided by Administrator on 2/19/23 at 1:44 p.m., read as follows: PM Sunday-Fryer (drained, completely cleaned, replace oil, scrub the whole thing inside and outside clean with degreaser) .PM Monday-Stove/Oven (burners to be taken off and cleaned, shelf and backsplash clean and wipe with degreaser, doors and sides clean and wipe with degreaser, inside oven scrubbed clean, oil drip tray scrubbed clean with degreaser) .PM Wednesday-Scrub floor (scrub floor form backsplash to steamtable, from reach in to coffee station) .AM Saturday- Steamtable (around wells need to be scrubbed clean, on top of shelf and under shelf needs to be scrubbed clean, sides and where knobs are need to be scrubbed and cleaned, pull everything out from bottom shelf and needs to be scrubbed and cleaned with degreaser.<BR/>Record review of undated Nutrition Orientation & Competency Policies And Procedures provided by Administrator on 2/19/23 at 1:44 p.m., read in part: FLOORS .There is usually an established routine for cleaning the floors in the food areas. It is important to maintain this routine to assure a clean Nutrition/Culinary Services Department. The routine usually includes sweeping several times a day and mopping at least once a day.<BR/>Record review of The Food and Drug Administration Codes October 2015, 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils indicated:<BR/> . (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch. <BR/>(B) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. <BR/>(C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue and other debris .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to adequately equip residents' rooms to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for 11 of 11 rooms, reviewed for communication system, in that:<BR/>Residents did not have a functional call light or communication system in their rooms.<BR/>This failure could affect residents and could result in a diminished quality of life, and injury due to not being able to call for assistance.<BR/>Findings included: <BR/>Interview and observation with Resident #44 on 09/27/2022 at 09:40 A.M. There was no call light present in the room. The resident stated when she needs help, she calls out for help. She stated that staff check on her every 20 mins or so and she had no complaints or issues. There was no call light in the resident's room.<BR/>Interview on 09/27/2022 at 10:29 A.M. with RN 2 stated that most times they make rounds every hour, the residents don't have call lights because of safety nets, to prevent injury to themselves. Some of them chew on it and that's not safe. When asked who is chewing on the cords she stated that was an assumption. She stated some residents tear up paper towels and try to eat them. We do whatever we can and we also don't want them to hang themselves. To monitor the residents, if between rounds if staff don't see a resident in the dining room they go and look for them and check on that resident. There is always someone around to hear or see if a resident needs help and they call on us if they need help.<BR/>Interview on 09/29/2022 at 1:28 P.M. with Maintenance Director stated the call lights in all of them are down for safety reasons. The call lights have not worked in the since he's been here they have not worked. He started in 2020 and the unit has been that way since 2017. He stated that the call lights in the rooms are tied into the ones in the bathrooms. Interventions that are used in place of the call lights are the nurse and CNA are present at all times and they walk the floors every 15-20 mins. If residents are not in the dining room they walk the floor and check on residents, if they're in the restroom they check on them there.<BR/>Interview on 09/29/2022 at 2:04 P.M. with Administrator stated that Maintenance Director said the call lights have not worked since 2017 and that staff constantly walk the halls to monitor the residents. <BR/>Interview on 09/29/2022 at 2:09 P.M. the Specialist who stated that she spoke with the Maintenance Director who stated that the call lights are not present for safety reasons that the residents would get entangled with the cords and also why there are no curtains and only blinds on the windows. The CNAs and the RN are always in the unit and don't leave until someone else replaces them. She stated that there is no official specific written policy for the secured unit regarding not having call lights in place.<BR/>Interview on 09/29/2022 at 2:35 P.M., In place of call lights, the facility has staff do frequent rounds. RN 2 stated they do not have a log of when rounds have been done. In the mornings there are 2 CNAs, the afternoon there is 1 CNA, 1 RN, and at night 1CNA, 1 LVN in the hall. She stated that if the CNA is doing something with a resident, then she will be watching the residents. Tues for example, the ADON came in to replace the CNA. She stated that she takes lunch in the office in the hall.<BR/>Interview on 09/29/2022 at 2:44 P.M., with CNA C, In place of call lights, the facility has staff do frequent rounds. she does rounds every shift. Every 8 hours she does rounds. She checks on the residents, talks with other CNAs and inform them of what's been happening. If she is dealing with a resident, then when she finishes with the current resident then moves on to the other resident. When she takes a break, the nurse watches the residents.<BR/>Interview on 09/29/2022 at 2:48 P.M., with Resident #44 stated that staff are constantly walking up and down the hall, or every 15-20 minutes. She was asked what she would do if she needed assistance or help. The resident stated stated that if she needed help with something she would call out for staff. She also stated that sometimes visitors are here to help and they would get staff's attention.<BR/>Observation on 09/29/2022 at 2:55 P.M., of Specialist, Maintenance director, and the Administrator. They attempted to plug in call light cords into the wall to test the call lights in room [ROOM NUMBER]. An alarm sounded somewhere, but neither the light on the wall in the resident's room or the light outside above the resident's room lit up.<BR/>Interview on 09/30/2022 at 11:22 A.M., with the MDS Nurse. She stated regarding delays in resident care that there are none that she's aware of. She has not seen or heard of residents receiving delayed care due to the lack of call lights. They make such frequent rounds. Even when there are falls we find them quickly. They recently starting today, 09/30/2022 started doing rounds every 10-20 minutes. She stated we didn't have a set time when doing rounds before, but there was always someone walking around keeping an eye on residents. She was asked if it was just her just her working how would she handle multiple residents needing assistance. She stated there are always at least 2 staff. There has never been only one staff in the unit. She stated she was MDS before, but she became weekend nurse recently. Only issue was when a staff couldn't remember a password and they were banging on the door, but in a pattern and she knew it was staff. No resident has had delayed care. If she needed additional help she would call for staff on their cell phone. She has each other's phone numbers. If needed, they could also open the fire door and ask for assistance. She would just yell out that she needed help after opening the secured door. During our interview she was observed to have done a round check on the residents. <BR/>Interview on 09/30/2022 at 11:25 A.M. with CNA A stated she's been working here since June, she usually works 100 Hall, but she does rotate working other halls. She has not seen or heard of residents receiving delayed care due to the lack of call lights. She was asked if there were no other staff in the hall she stated and if she's dealing with a patient and the other staff is resident busy, before she handles her resident then she would get additional assistance from another hall, a CNA, or a nurse. She stated that if both staff were in emergency situations with residents, she would stop what she's doing, ensure the resident is ok temporarily, and get additional assistance. If it's an emergency, she would cover them, lock the wheelchair if applicable, and she would walk out and get the help. She was asked what she would do when there is only one staff is in the hall she stated that since she's been here, she's never worked alone, there has always been other staff working in 300, it's another CNA and a nurse.<BR/>Interview on 09/30/2022 at 11:37 A.M. with CNA B when asked how often a resident has been delayed care because of a staff did not know that a person needed care. She has not seen or heard of residents receiving delayed care due to the lack of call lights. She stated she is going to handle the resident she is with first, and then call out for help. If there is only the nurse and the aid back here. She would triage the current resident and see about the other resident that needs assistance. She was asked what she would do when there is no other staff in the hall She stated she has never been worked alone. There are always 2 staff, a CNA and a nurse. She was asked what to do to get help. She stated she would verbally call out or blows her (personal) whistle, or she would call someone from the office to the outside. She would evaluate the situation with the current resident before leaving to make the call first.<BR/>Interview on 09/30/2022 at 11:45 A.M. with Specialist, stated that the facility has implemented rounds checks in the 300 hall for staff and created a log book where staff will log each time their rounds were completed due to the lack of call lights in the hall. Staff know to call out for help via through the fire door, using their cell phones, or having another staff temporarily leave the hall to get additional assistance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment, for daily living for five of fifteen residents (Resident #5, Resident #24, Resident #27, Resident #29, Resident #55) reviewed for environmental concerns. <BR/>Odors of urine were in the resident rooms and or bathrooms of Resident #5, Resident #24, Resident #27, Resident #29, Resident #55<BR/>These failures could place residents at risk of living with unclean, uncomfortable, un-homelike rooms permeated with the odor and presence of urine. <BR/>Findings include:<BR/>In an observation on 09/27/22 at 9:30 a.m., Resident #5, was not present in the room at the time, but Resident #27 was. The room smelled of urine. Resident #5 was in the dining room area with other residents. <BR/>In an observation on 09/27/2022 at 09:30 AM of room for Resident #29 the room smelled of urine. There were no physical signs of urine in the room. The resident was not present in the room.<BR/>In an observation on 09/27/2022 at 09:50 AM of room for Resident #55 the room and restroom smelled of urine. The resident was not present in the room.<BR/>In an observation on 09/27/2022 at 10:12 AM of room for Resident #24 the restroom smelled of urine. The resident was not present in the room.<BR/>In an observation and interview on 09/28/22 at 1:35 PM revealed the odor was still present in the Resident #5' and Resident #27's room. CNA D observed the odor and stated that it is a problem because he and other residents will urinate in the rooms, in trash cans, in the drawers, and in the closets. <BR/>In an interview on 09/28/2022 at 1:45 PM with Housekeeping A<BR/>The aids are in charge of changing the linens. She stated that she thinks daily or at least every other day they are changed. The linens are changed by the CNAs. For hall 300 she works all day from 630 AM-3 PM. She pulls the trash, wipes furniture, cleans the bathroom, sweeps and mops and restocks paper towels and wipes the handrails and sweeps and mops the hallways. She stated that Resident in RM [ROOM NUMBER]- Resident #1 urinates in floor, urinates in closet, and drawer. She uses a cleaning solution, deodorizer. She stated that the resident even urinates in the trashcans and in other residents' room. <BR/>She stated that staff take him to the restroom when first getting up. Resident #55 can become physical at times and when they try and get him to the restroom to prevent him urinating outside the restroom.<BR/>She stated she wipes the furniture and cleans behind it and she's talked to Maintenance Director about possibly replacing the furniture and they try and keep ahead of things.<BR/>In an observation and interview on 09/29/22 at 09:30 AM revealed the odor of urine was gone from all five of the resident's rooms.<BR/>Record review of the Infection Control Checklist dated 2022 and completed quarterly stated that the Cleaning Procedures listed were met for the third quarter. The cleaning procedures were not listed on this document.<BR/>Record review requested by this survey from the Administrator for the cleaning policy which was undated titled, admission Room-Ready Prep & Guarantee form listsed that Housekeeping cleans: bed frames, headboard and footboard, call light cord and bed control & TCV remote, drawer fronts, closet doors all sides of bedside table, room chair legs and seating, floor & wall protectors, window blinds, window track and sill, exterior of Packaged Terminal Air Conditioner (PTAC) unit, light fixtures, remove any tape on walls, lights, doors, closet door, drawer, inside and out & hardware, bathroom door and walls, bath fixtures and floors, bath emergency pull cord, toilet surfaces and floor edge, overbed tabletop, underneath and base (hair & strings out of wheels), TV screens top and sides, and finally walls.

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