**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident record review, interviews, review of a facility policy titled AGAINST MEDICAL ADVICE (AMA), and review of a facility policy titled Notification of Change of Condition of a Resident the facility failed to ensure the Physician was notified when Resident Identifier (RI) #1 left the facility AMA. This had the potential to affect RI #1, one of three sampled residents. Findings include: A review of a facility policy titled AGAINST MEDICAL ADVICE with a last review date of 10/2022, revealed: . POLICY: AGAINST MEDICAL ADVICE (AMA) . C: Sign Out AMA PURPOSE: To provide consistent guidelines for staff to follow under applicable circumstances . PROCEDURES: . 2- Notify the physician and follow any instructions/orders given. A review of a facility policy titled Notification of Change of Condition of a Resident, with a revised date of 09/2011 revealed: . Purpose: To ensure resident's rights and continuity of care by identifying and reporting a Significant Change in Physical, Mental and Psychosocial well being. Procedure: Notify the Physician of status change. RI #1 was admitted to the facility on [DATE] with a diagnosis of Aftercare Following Joint Replacement Surgery and Right Artificial Knee. RI #1's Departmental Notes documented the following: . 11/25/2022 12:40 PM . Nursing Note . admitted to room . and . Patient left AMA @ 2200 hours (at 10:00 PM) . Patient transported from facility via wheelchair by personal vehicle. An interview was conducted via phone on 07/06/2023 at 12:06 PM with Employee Identifier (EI) #3, Registered Nurse. EI #3 was the nurse for RI #1 on 11/25/2022 at 10:00 PM. EI #3 was asked about RI #1 leaving AMA. EI #3 said, a family member came to the facility and was going to take RI #1 home. EI #3 said, she called the Director of Nursing (DON) to let her know. On 07/06/2023 at 4:28 PM a follow up interview was conducted with EI #3, and she was asked who she should have notified about RI #1 leaving AMA, and she answered, the Medical Director. EI #3 was asked what the facility policy was for notification. EI #3 said, when there was a change in status of any kind, they were to notify the Doctor. EI #3 was asked what the concern was of not notifying the Doctor when there was a change. EI #3 said, so the doctor could give further orders. An interview was conducted on 07/06/2023 at 5:01 PM with EI #2, the Director of Nursing. EI #2 was asked who should the nurse notify if a resident leaves AMA. EI #2 said, the Physician. EI #2 was asked what the concern was of not notifying the Physician of a resident leaving AMA. EI #2 said the doctor needed to be notified in case further orders needed to be given. An interview was conducted via phone on 07/06/2023 at 5:47 PM with EI #1, the Medical Director. EI #1 was asked when he was notified of RI #1 leaving AMA. EI #1 said, he was not notified. EI #1 was asked when he should have been notified of RI #1 leaving AMA. EI #1 said, when the resident left. EI #1 was asked why he should have been notified of RI #1 leaving AMA. EI #1 said, they might could have done something.

Based on observation, interview, review of a facility policy titled, Waste Disposal and review of the, 2017 Food Code , the facility failed to maintain the areas surrounding the dumpster in a condition free of debris to prevent insect and rodent attraction. This deficient practice had the potential to affect all 18 residents residing in the facility. Findings Include: A review of an undated facility policy titled, Waste Disposal, documented: POLICY: To provide a safe sanitary environment . PROCEDURE: .8. Garbage dumpster's are to be leak proof, cleaned around . at all times . The 2017 Food Code by the United States Public Health Service (USPHS) and the Food and Drug Administration (FDA) included the following: . 5-501.15 Outside Receptacles . (B). Receptacles and waste handing units for REFUSE .shall be installed so that accumulation of debris and insect and rodent attraction and harborage are minimized and effective cleaning is facilitated around and .under the unit . On 11/ 06/18 at 3:52 p.m., the surveyor observed the dumpster area with EI (Employee Identifier) #1, Dietary Manager. The surveyor observed debris around the dumpster to include wrappers, plastic clear cups, clear top lids and medication cups on the ground around the dumpster. EI #1 was asked to describe what was on the ground around the dumpster. EI #1 said, Wrappers, clear cups, lids, other paper and trash. EI #1 was asked if debris should be on the ground around the dumpster area. EI #1 said, No it should not be there. EI #1 was asked who was responsible for ensuring the dumpster area was free of debris. EI #1 said, It ultimately falls on me. EI #1 was asked what was the potential harm with debris on the ground around the dumpster area. EI #1 said, It could cause rodents.

Based on observations, an interview, a review of a facility document titled, Mighty Shakes, and a review of policy and procedures titled, Mighty Shake Policy and Procedure and Use of Leftovers, the facility failed to ensure: 1. two mighty shakes were not observed in the walk-in cooler without a thaw date or a use by date and 2. a baking sheet with twenty-five raw strips of bacon were not observed in the walk-in cooler with a use by date of 10/15/2017 on the initial tour of the kitchen on 10/17/2017. This was observed on one of three survey days and had the potential to affect all fifteen residents receiving meals from the kitchen. Findings Include: 1. A review of a document titled Mighty Shakes, revealed: Mighty Shakes, . Special Notes No preparation necessary. Just simply thaw and serve. Has a refrigerated shelf life of 14 days (unopened) . A review of a policy titled, MIGHTY SHAKE POLICY AND PROCEDURE, dated 12/04/2012, revealed: MIGHTY SHAKES are to be dated when removed from the freezer and placed in the cooler. This date becomes the THAW DATE, which will be identified by a colored sticker (other than white). date with a thaw date and the expiration date which is 14 days from the thaw date. An observation was made on 10/17/2017 at 3:56 p.m. on the initial tour of the kitchen. Upon entering the walk-in cooler, there was a serving tray with eight thawed mighty shakes. Two of the eight mighty shakes had no thaw date or use by date on them. 2. A review of a policy titled, Use of Leftovers, revealed: Policy: Excessive leftovers should be avoided. Leftovers will be properly handled and used or discarded as appropriate. Procedure: . 2. Leftovers will be covered, labeled, and dated; then stored . 5. Any food that is leftover will be handled . and may be used as follows : . Use leftovers within 3 days or discard . An observation was made on 10/17/2017 at 3:56 p.m. on the initial tour of the kitchen. While in the walk-in cooler, a baking sheet was observed on a stackable food cart. The surveyor observed 25 raw strips of bacon on the baking sheet. The cover over the bacon was dated with a use by date of 10/15/2017. On 10/19/2017 at 2:50 p.m., an interview was conducted with EI (Employee Identifier) #1, the Dietary Manager. EI #1 was asked what the facility policy and procedure was regarding dating Mighty Shakes when thawed. EI #1 replied they were good for two weeks from the thaw date. EI #1 said they were thawed by running cool water over them until thawed, then a thaw date and a used by date were to be written on them and they were to be placed in the cooler. EI #1 was asked what was found in the walk-in cooler on 10/17/2017. EI #1 replied two undated Mighty Shakes. EI #1 was asked what else was found in the walk-in cooler. EI #1 replied raw bacon dated for the 15th, the discard date. EI #1 was asked what the potential concern was for the above two items identified in the walk-in cooler. EI #1 replied it could make the population sick, the residents or the staff.