Based on observations, record review, interview, facility document review, and facility policy review, it was determined that the facility failed to ensure behavioral health services were provided to meet the needs of a resident with a history of suicide and a family history of suicide. Specifically, the admission nurse did not include the resident’s suicide history in the Care Plan, and facility staff were not trained to identify or respond to behavioral health needs for one (Resident #1) of one sampled resident reviewed for death. The findings include: During an observation on 08/11/2025 at 1:19 PM, all of Resident #1’s belongings had been removed from their room, except for their mattress. This surveyor observed the closet and railing where the incident took place. During an observation on 08/11/2025 at 2:25 PM, while in the Administrators office, the Administrator showed this surveyor a clear bag which contained the remaining shoestrings that were cut from the closet railing. The shoestring that was around Resident #1’s neck was left on but cut off at the neck. This surveyor then observed a pair of white and gray shoes in a box, with the strings removed. The Administrator stated Resident #1’s family wanted the residents’ remaining clothes and shoes to be donated to charity. During an observation on 08/11/2025 at 3:00 PM, the Housekeeping Supervisor showed this surveyor the large clear bag of clothes and shoes that had been removed that morning from Resident #1’s room. She stated maintenance personnel would take the bag to a donation center, as instructed by the family. During a concurrent observation and interview on 08/12/2025 at 9:15 AM, this surveyor attempted to interview Resident #1’s roommate, however, the roommate did not respond. A review of a facility document titled Facility Assessment, dated 10/31/2024, indicated the facility offered services and care related to psycho/social/spiritual support, by making sure staff that cared for the resident had the information; supported emotional well-being and helpful coping mechanisms. Staff competencies on caring for residents with mental and psychosocial disorders, as well as residents with a history of trauma and/or Post-Traumatic Stress Disorder (PTSD) with implemented interventions. Residents with behavioral symptoms and cognitive performance would have a nursing distribution percentage of 5.03%. A review of Resident #1’s admission Record, indicated the facility admitted the resident on 02/07/2025, for rehabilitative services due to a pubis fracture, and with diagnoses that included major depressive disorder, anxiety disorder, and a personal history of suicidal behavior. A review of Resident #1’s [Local Hospital] Geriatric Behavioral Health Documents, dated 01/09/2025-01/27/2025, indicated the resident was admitted to the Geri-Psych facility for depression, anxiety, and an intentional self-harm drug overdose. Resident #1 was administered medications for these diagnoses. Further review of Resident #1’s Geriatric Behavioral Health Documents revealed the resident had a family history of suicide, which include one immediate family member that committed suicide and another immediate family member that attempted suicide. On 01/26/2025 the day before discharge, the psychiatrist had documented the resident was withdrawn, positive for suicidal ideas, seemed lonely, and the resident mentioned to the physician they seemed a little anxious and depressed over this fall. A review of Resident #1’s admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/10/2025, revealed a Brief Interview of Mental Status (BIMS) score of 12, which indicated Resident #1 had moderate cognitive impairment. Resident #1’s MDS also revealed the symptom of thoughts that you would be better off dead, or of hurting yourself in some way was not addressed, and the symptom of feeling down, depressed or hopeless was coded as not present. Further review of Resident #1’s MDS revealed the resident was coded as rarely for feeling isolated or lonely from those around you. Furthermore, Resident #1’s MDS revealed the resident had active diagnoses, which included anxiety disorder and depression and that the resident was actively taking an antidepressant and an anticonvulsant. A review of Resident #1’s quarterly MDS with ARD of 05/13/2025, revealed a BIMS score of 12, which indicated Resident #1 had moderate cognitive impairment. Resident #1’s MDS also revealed the symptom of thoughts that you would be better off dead, or of hurting yourself in some way was not addressed, and the symptom of feeling down, depressed or hopeless was coded as not present. Further review of Resident #1’s MDS revealed the resident was coded as rarely for feeling isolated or lonely from those around you. Furthermore, Resident #1’s MDS revealed the resident was independent in their care, had active diagnoses which included anxiety disorder and depression, and the resident was actively taking an antidepressant and an anticonvulsant. A review of Resident #1’s Care Plan, dated 02/07/2025, revealed the resident had a diagnosis of major depressive disorder, was on routine and as needed pain medication, used anti-depressant medication, and had the potential for nutritional problems related to major depressive disorder. Resident #1’s Care Plan included interventions to observe for acute sadness, interest in activities, change in sleep patterns, loss of appetite, administer medications as ordered, monitor and document side effects, and monitor for social isolation, depressive mood/behavior, anxiety, changes in usual routine, suicidal thoughts, withdrawal and insomnia. A review of Resident #1’s Care Plan Meeting Invitation, dated 07/31/2025, revealed the facility had a scheduled Care Plan meeting dated 08/13/2025 at 11:30 AM, with Resident #1 and their family. A review of Resident #1’s Physician Progress Note, dated 02/07/2025, revealed the resident had been in Geri-Psych for depression and it was found Resident #1 had not been taking their prescribed medications while at home. All of Resident #1’s behavioral medications were restarted after admission to Geri-Psych, with improvement to their mood. Resident #1 and their family opted for the resident to go to long term care. A review of Resident #1’s Medication Administration Record (MAR), dated 02/2025, revealed the resident was on a medication for major depressive disorder which was discontinued on 02/17/2025, and medications for insomnia, major depressive disorder, Parkingson’s, pain, and tremors. A review of Federal Drug Administration Package Inserts, indicated the side effects for the medications Resident #1 was taking were insomnia, depression, anxiety, suicide, disorientation, impulsive behavior, psychosis, dementia, suicidal behavior and ideation, mental impairment, abnormal thinking, and emotional instability, A review of Resident #1’s Progress Notes, dated 02/07/2025 -08/11/2025, indicated there were ongoing assessments regarding Resident #1’s behaviors. A review of Resident #1’s Social Service Note dated 02/10/2025, revealed Resident #1 had a BIMS of 12, was oriented to person, place, time, situation, and had mental function that varied over the course of the day. Resident #1’s Social Service Note revealed diagnoses which included major depressive disorder and anxiety disorder. Further review of Resident #1’s Social Service Note revealed a Patient Health Questionnaire-9 (PHQ-9) score of 00, which indicated no depression. Furthermore, the residents Social Service Note indicated Resident #1 did not have a history of difficulty coping, therefore PTSD/trauma would not be addressed on the Care Plan. A review of Resident #1’s Social Service Note dated 05/13/2025, revealed Resident #1 had a BIMS of 12, was oriented to person, place, time, and situation. Resident #1’s Social Service Note revealed diagnoses which included major depressive disorder and anxiety disorder. Further review of Resident #1’s Social Service Note revealed a PHQ-9 score of 00, which indicated no depression. Social isolation was marked as rarely, which triggered mood state to be addressed on the Care Plan. Furthermore, the residents Social Service Note indicated Resident #1 did not have a history of difficulty coping, therefore PTSD/trauma would not be addressed on the Care Plan. A review of Resident #1’s Weight Warning Progress Note dated 07/30/2025, indicated Resident #1 had dropped 5.2 pounds in one week with a food intake of 77% that day [07/30/2025]. Further review of the residents Weight Warning Progress Note revealed Resident #1 had updated their food preference on 07/28/2025 and walked around the building all day and exercised in their room. Staff were to monitor the resident weekly. A review of Resident #1’s Progress Notes revealed Resident #1 stated on a nursing general note on 02/07/2025, that Yes, I have my apartment. I am here for a little while then yeah. The residents Progress Notes also revealed nursing had multiple entries of Resident #1’s complaints of pain. A review of Resident #1’s Progress Notes revealed on 03/17/2025, Resident #1 had an increase of medication for neuropathy pain, which had side effects of suicidal thoughts and depression. A review of Resident #1’s Progress Notes revealed on 05/28/2025, Resident #1 requested the as needed pain medication to be administered at bedtime as scheduled. The resident did not like to bother staff when they were in the middle of their medication pass. A review of Resident #1’s Progress Notes revealed on 07/28/2025, Resident #1 complained of right shoulder pain and had an x-ray done with no fractures. A review of Resident #1’s Progress Notes revealed on 08/06/2025, the resident saw the physician during rounds with complaints of pain all over. The physician increased Resident #1’s neuropathy pain medication at bedtime to 200 milligrams (mg) from 100 mg, which had side effects of mood changes and increased risks of suicidal thoughts or actions. A review of Resident #1’s Progress Notes revealed on 08/10/2025, Resident #1 was found at 5:25 AM, hanging in the closet with body hanging from the neck, knees to floor, no pulse, no respiratory effort, blood pooling in feet/lower legs, skin color white, cold to the touch. Do Not Resuscitate (DNR) status was verified. A review of the Arkansas Incident Report dated 08/10/2025, indicated the police officer entered Resident #1’s room and saw the resident hanging from the coatrack of the closet by what appeared to be a shoestring. An investigation was done with the case closed as a completed offense status. A review of a facility document titled In-Service on Residents Behavior dated 08/10/2025, indicated the facility held an in-service after the incident on what to look for in a resident’s behavior, such as decreased appetite, decreased interaction, self-harm, voiced self-harm, or mental health signs or symptoms. The staff were instructed to report these behaviors immediately to the charge nurse and protect the resident. During an interview on 08/11/2025 at 1:23 PM, Licensed Practical Nurse (LPN) #1 stated she saw Resident #1 last on 08/07/2025, and was informed of the incident this morning [08/11/2025] in report. She stated the resident had walked around the facility, visited with other residents, played bingo, and never acted differently while she worked. LPN #1 stated Resident #1 was independent, while the roommate was dependent and that staff checked on Resident #1 when they provided care for the roommate. During an interview on 08/11/2025 at 1:39 PM, the Director of Nursing (DON) stated she had 34 missed calls, on 08/10/2025, the morning the facility tried calling her. She arrived at the facility around 6:00 AM, and the police had left, but the coroner was still there. The Administrator and DON spoke to the night shift Registered Nurse (RN) #5, and asked if Resident #1 acted any out of the ordinary and the nurse stated, No. The DON stated Resident #1 had gotten new tennis shoes last week and walked into the DON’s office to show them to her. The resident sat down in a chair and bragged about getting a size 15 shoe, when they wore an 11, because the resident said they did not like their shoes tight. The DON described Resident #1 to have been a very tall person, around 6 feet. During an interview on 08/11/2025 at 1:56 PM, the Activities Director (AD) stated Resident #1 was a very tall person around 6 feet, and participated in the facility activities, especially bingo. The AD stated Resident #1 was always smiling. During an interview on 08/11/2025 at 1:58 PM, the Assistant Director of Nursing (ADON) stated she arrived at the facility on 08/10/2025, between 6:40 AM-6:50 AM, after the investigators and coroner arrived. The ADON stated she saw them cut Resident #1 down and let Resident #1 fall to the floor. The resident landed on their right side with their back facing the closet with the front of the body facing the footboard of the bed, and their legs bent. Resident #1 had on a white t-shirt and boxers, no socks or shoes. Resident #1’s roommate had already been removed. The ADON stated Resident #1 had an increase to their medication last week for pelvic pain and neuropathy and the physicians saw Resident #1 every other Wednesday for pain. During an interview on 08/11/2025 at 2:12 PM, the Administrator, the Nurse Consultant, and a member of the governing body were in the Administrators office. The Administrator stated she was notified around 5:30 AM, by RN #5 that a resident had hung themselves. The Administrator stated, I instructed her to call 911 and the police. I arrived at the facility at 6:00 AM and received an update from the staff. The family had been notified by the RN on duty prior to my arrival. The coroner informed the Administrator that Resident #1 was found with shoestrings around their neck and was on their knees. The Administrator stated she did not know Resident #1 and had only met them just a couple of times, since she started in July of 2025. She stated she looked through Resident #1’s cell phone to see if there had been a note or message left. The Administrator confirmed no note or message was found, and the last text was sent to the resident’s family member around 10:30 PM, with no typed message just a picture of a green tractor. Resident #1’s dresser drawers were also checked for a note, and nothing was found, per the Administrator. During an interview on 08/11/2025 at 4:25 PM, the Deputy Coroner stated he was notified around 5:57 AM and arrived on scene at 6:09 AM. The Deputy Coroner stated, as he was walking through Resident #1’s room, he took pictures. He stated he noticed there were two beds in the room, a curtain divided the two beds, and it was pulled open so both beds were visible. The right closet door was opened about 90 degrees, so you could not see inside of the closet from the doorway. The Deputy Coroner stated when he stepped around the door, Resident #1 was hanging by the neck, it was later determined it was shoestrings that were used. Resident #1 was 6’ tall. He verified Resident #1 had tied the knot that put pressure on the front of their neck and had the strings so tight that it cut off the carotids and the resident probably passed out after 15-20 seconds. The Deputy Coroner stated the shoestring was tied at the highest point in the closet, the residents’ knees were bent 90 degrees, and their feet were toward the outside of the closet. There were deep ligatures in the front of the neck, where most of the pressure was and along the jaw line, lower mandible of the neck. There was mild blood pooling in the residents' lower legs when the coroner arrived and was worse before he left. The Deputy Coroner stated rigor mortis had not set in yet, which usually takes four to five hours and would have started in the jaw and neck area, but since the resident was hanging, it would not be seen due to the trauma of the neck area. He then stated the residents’ fingers and arms were still pliable, and that a nylon shoestring was strong enough to withstand Resident #1’s weight and hanging. The Deputy Coroner stated no foul play was suspected, and that he spoke to Resident #1’s family member on the cell phone while at the hospital and the family member stated, [the resident] finally did it and had talked about doing it for a long time. The resident hated being in the nursing home and admitted self to the facility to not be a burden on the family. The Deputy Coroner stated, if a person was thinking of suicide and they had a plan, they would act normal to force people and make people think they were okay. During an interview on 08/11/2025 at 4:52 PM, CNA #2 stated she was the one that found Resident #1 in the closet. She stated she was working the hall with two other CNAs and the female residents on the 400-hall did not want male staff to change their briefs, so the CNAs decided to split the hall. CNA #2 and CNA #6 would round on the female residents, and CNA #3 would round on the male residents. CNA #3 checked the residents in Resident #1’s room at 2:30 AM. At 5:25 AM, CNA #2 and CNA #6 finished the female residents before CNA #3 finished the men, so CNA #2 went into Resident #1’s room to change, dress, and get up the dependent roommate. CNA #2 turned on the night light so it would not wake up Resident #1. As CNA #2 was walking to the closet, she noticed Resident #1 was not in bed and assumed the resident had already gotten up and walked to the kitchen, so she opened both of the closet doors. CNA #2 stated she had to let her eyes adjust because it was still dark in there but noticed Resident #1’s feet and jumped back and was about to help, when she saw Resident #1 was hanging. She stated, I freaked out, screamed, and took off running down the hall. CNA #2 stated she could not get the words out. CNA #3 took off to Resident #1’s room and came out and stated to RN #5, Oh my God, the resident hung themself. CNA #2 stated the RN told the CNAs they had to remove the roommate immediately, but CNA #2 said, I could not go back in there. CNA #2 confirmed she wrote a statement for the police and facility without coercion from anyone at the facility on the wording used in the statements. During an interview on 08/11/2025 at 5:20 PM, CNA #3 stated when he got to work on 08/10/2025, there were three CNAs scheduled on that hall and he immediately thought to himself, we are going to have a good night. The CNA stated the CNAs split the hall, and he had all the male residents. The CNAs did rounds at 2:30 AM and again around 5:25 AM. CNA #3 stated he had gotten behind, so CNA #2 walked into Resident #1’s room to help CNA #3 finish the hall. CNA #3 stated he heard a scream and CNA #2 came running out of the room, so he asked CNA #2 what happened, and CNA #2 could not talk, but said closet. CNA #3 stated he walked into Resident #1’s room, saw the closet doors were opened and saw Resident #1 hanging. CNA #3 revealed he was freaked out. CNA #3 described Resident #1 as having had on a white t-shirt and boxers, their legs were really purple and bent, the front of their body was facing the left wall of the closet, and the resident’s knees were not touching the bottom of the closet, they were about six inches from the ground. CNA #3 described the resident as a tall person, around 6’-6’1 inch. CNA #3 stated, You see this on television and think that is all made up, but it is not. All the resident had to do was put their feet down and stand up. CNA #3 stated he could not see Resident #1’s neck area, the residents’ head was hunched over, and their eyes were halfway closed. CNA #3 stated staff immediately got the roommate out of the room and left Resident #1 alone until the police arrived. CNA #3 then stated staff locked down the hall and kept all the residents in their rooms, until things settled down. During an interview on 08/12/2025 at 9:22 AM, Resident #2, a resident on the 200-hall, wheeled themselves in a wheelchair down the 400-hall towards Resident #1’s room when this surveyor asked the resident their name. The resident stated the last time they saw Resident #1 was on Saturday, 08/10/2025, during the day. Resident #2 stated Resident #1 always complained of headaches and neuropathy, did not like the food here, and often spoke about how sad they were because their spouse passed away 10 years ago. Resident #2 stated they received a voicemail Saturday night with Resident #1 being a jokester asking if I wanted to go out to eat dinner, then said oh yeah, we cannot leave the facility. Then Resident #2 stated Resident #1 said, Thank you for the refrigerator, I will see you at church in the morning. Resident #2 stated, staff told me that [Resident #1] did not wake up. During an interview on 08/12/2025 at 12:22 PM, CNA #4 stated she worked with Resident #1 all the time and gave the resident a shower on Saturday, 08/10/2025. She stated the resident never acted differently than normal. CNA #4 revealed Resident #1 was independent and would get their roommate ice water and would go to Resident #2’s room on the 200-hall to visit. She stated, the resident did make statements all the time about missing their spouse and did not understand why God kept them here but never made statements of suicide or comments related to what happened. During an interview on 08/12/2025 at 3:36 PM, RN #5 revealed she was late administering medications on Saturday night, 08/10/2025, and informed Resident #1 of it, to which the resident responded, No rush. During rounds at 2:30 AM, Resident #1 was in bed. RN #5 stated she always saved Resident #1’s rooms morning medications for last, so the residents could sleep longer. RN #5 stated as she was at the end of the hall when she saw CNA #2 running out of Resident #1’s room and was hysterical. RN #5 stated CNA #2 was shaking and backing down the hall toward the desk. CNA #3 heard CNA #2 scream, came down the hall and entered Resident #1’s room. CNA #3 came out and told RN #5 what happened, and RN #5 ran into the room and saw Resident #1 hanging with their body toward the window. The resident had a string around their neck, their legs were bent, their knees were off the floor, and their feet were touching the floor. RN #5 stated she checked Resident #1 for a pulse and respiratory effort, but there was not any. RN #5 stated she knew the resident had a DNR code status. She described that Resident #1 was cold to touch, pale, white, and their legs were reddish in color. RN #5 stated she called the DON and ADON, with no answer. She then called the Administrator, 911, the police, and Resident #1’s family. RN #5 reported off to each of them as they arrived. The Deputy Coroner arrived and spoke to Resident #1’s family member on the cell phone. RN #5 stated she never knew Resident #1 had a recent suicide attempt before admission to the facility, but she had overheard Resident #1’s family member tell the coroner that. RN #5 stated staff did close the 400-hall doors to block traffic and kept all residents in their rooms until everything calmed down. Resident #1’s roommate was immediately removed from their room, prior to the arrival of the police. During an interview on 08/12/2025 at 5:03 PM, CNA #6 stated when she got to work on 08/10/2025, there were three CNAs for the 400-hall, so they split it up the residents by male and female. CNA #2 and CNA #6 would take care of all the female residents and CNA #3 would take care of the male residents on the 400-hall. CNA #6 stated they made rounds at 2:30 AM, and she never saw Resident #1 at that time, but CNA #3 did. At 5:25 AM, CNA #6 stated they finished the female side before the male side, so they helped CNA #3 finish the male residents in order to be done. CNA #2 entered Resident #1’s before CNA #6 made it up there and as CNA #6 was putting her gloves on she heard a scream, and CNA #2 came running out of Resident #1’s room hysterically. CNA #6 revealed she went into the room and peeked around the corner, saw Resident #1 hanging with something white around their neck. The residents' legs were bent, they had a t-shirt was on, there was a shirt on a hanger laying across Resident #1’s bed, and CNA #6 revealed she took off running. CNA #3 went into the resident’s room and came out to report to RN #5. RN #5 then went into Resident #1’s room and started calling management, the police and 911. CNA #6 stated RN #5 instructed us to get the roommate out of the room. CNA #6 revealed she could not go back in the resident’s room. CNA #3 and CNA #7 immediately removed Resident #1’s roommate. CNA #6 stated she was given a statement to write by RN #5 and was instructed to put the last time she saw the resident was at 2:30 AM, but I did not see the resident at that time, so I did not put that down on my statement. During an interview on 08/13/2025 at 8:26 AM, LPN #8 revealed to know how to care for a resident, they were to look at the residents' closet Care Plan, look in the chart, or ask staff that had worked with the resident. LPN #8 stated the admitting nurse would fill out the closet Care Plan, if it was at night. During the day, the ADON or nurse would fill it out. If a resident had a history of suicide or suicidal ideations, it would be on their Care Plan or in their chart. LPN #8 stated she did not know Resident #1 had a prior suicide attempt. During an interview on 08/13/2025 at 8:36 AM, the Admission’s Coordinator (AC)/Medical Records/Infection Preventionist stated the admission of a resident was done by a group of people. The AC stated she would be informed when a resident was coming to the facility, and the diagnoses codes were entered along with details and orders. The AC stated she would take the telephone report and pass it to the nurse that would receive the resident. The AC revealed whatever nurse was on duty that day, would do the admission. The AC stated the facility had standard orders they followed and if a discharge packet was received, she entered the medications in the queue but did not activate them. Then the doctor would review the medications, and they would get activated. If the doctor wanted to make changes, he would call the facility. The AC then stated the MDS Coordinators did the assessments. During an interview on 08/13/2025 at 9:27 AM, RN #9 stated she had been the treatment nurse for the past two weeks, and prior to that was the RN on the 400-hall. To care for a resident, staff looked at the closet Care Plans, physician orders, talked to aides for residents’ personal preferences, and talked to the residents if coherent. RN #9 stated she worked with Resident #1 up until two weeks ago. RN #9 stated Resident #1 did not act differently and saw Resident #1 on Saturday, 08/10/2025. She revealed the resident told her They tricked you into coming in on Saturday, because Resident #1 liked to joke with people. Resident #1 mentioned having depression problems. RN #9 stated if a resident had a history of a suicide attempt, she thought it would be on the residents Care Plan, but she had never had a suicidal resident before. RN #9 stated she was not aware of looking for anything suicide related for Resident #1. RN #9 stated if a resident mentioned something odd or had behaviors, she would report it and would mention it to the CNAs. Resident #1 only saw the general doctors at the facility. The resident was an insanely sweet person and joked a lot; always sat around the fireplace and talked to everyone. I never saw it coming. During an interview on 08/13/2025 at 10:04 AM, CNA #4 stated she would look in the closet at the closet Care Plan to know how to care for a resident, or the nurses would mention what to do. CNA #4 stated if a resident was suicidal or had thoughts about it, the nurse would tell staff to watch out for it. CNA #4 stated no staff were aware that Resident #1 had tried to commit suicide prior to admission and was not told to look for anything on Resident #1. CNA #4 stated the resident did not see a psychiatrist, only the two general doctors at the facility. During a concurrent interview on 08/13/2025 at 10:10 AM: The Long-Term Care (LTC) MDS Coordinator, stated if a resident was admitted to LTC, she did the paperwork. Once a resident transitioned from rehab to LTC, she monitored the residents quarterly MDS. The LTC MDS Coordinator stated she would receive the resident’s information from a recent hospital stay or skilled services, and from their primary care physician (PCP) to develop the Care Plan. She then stated CNA documentation was looked at to add to the Care Plan. The LTC MDS Coordinator revealed she did not know Resident #1 had a suicide attempt prior to admission. Resident #1 always spoke, sat by the fireplace by the outside windows, loved to play bingo, and had to exercise and walk all the time. The Medicare Manager Rehab (MMR)/MDS Coordinator, she stated if a resident was admitted to rehab, she did the paperwork. She stated different people would input in the MDS, which included social services, dietary staff, the treatment nurse, and the activities director. When specific questions were answered on the MDS, it triggered for the Care Plan. The MMR MDS stated she received information from therapy to get function levels of the residents, from the nursing admission screen, documents from the hospital or from the facility the resident came from. It was a collaboration based on history from the PCP and inputs from other designations, such as nursing, and therapy. If a resident had a history of suicide attempts or ideation, it would be in their history and physical, care plan, and medical diagnoses. The MMR/MDS Coordinator stated she recalled reading Resident #1 overdosed on medications prior to being admitted to the facility and had been admitted to a Geri-Psych facility where the resident had sustained a fall and was subsequently sent to the hospital. The resident was then discharged home and then admitted to the nursing home facility per the decision of the resident and family. The MMR MDS stated when a resident was admitted with a major depressive disorder, the primary focus was for the current diagnosis and with that being said, hopefully being medicated and interventions would apply to that diagnosis. Suicide was not current diagnosis for Resident #1. She stated Resident #1 did not see a psychiatrist while at the facility, simply because the resident only saw that one while in the facility, no follow up was ordered and nursing documentation did not reference a change in behavior for the general doctors here to refer the resident to a psychiatrist. During an interview on 08/13/2025 at 10:47 AM, the DON stated staff would not know if a resident had a history of suicidal thoughts or attempts and would only know of active diagnoses. The DON stated, I think I knew Resident #1 had attempted suicide but had forgotten about it then re-read their paperwork after the incident. The resident did not have any signs or symptoms while here to remind us of the attempt. The DON stated Resident #1 did not have a follow up scheduled with a psychiatrist, so they only saw the general doctors at this facility. If the doctors saw any issues, they would have referred to a specialist. The resident’s family member told the coroner that the resident finally did it. The DON stated, you would think if they felt that way, they would have said something to us or that the resident was capable of doing this and would have shared that with us at the facility. I do not know if it would have changed the outcome but at least we would have known it. During an interview on 08/13/2025 at 2:20 PM, Administrator in Training (AIT) stated, she had started this position in the middle of June and had been the Social Director for the past 5.5 years. She worked with Resident #1 from February to June, and stated the resident was admitted in February to [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Surveyor: [NAME], [NAME] Based on observations, interviews, record review, facility document review, and facility policy review it was determined the facility failed to secure residents private health information on facility tablet to prevent unauthorized sharing of electronic medical record (EMR), while leaving the EMR open in the hallway without staff around for 1 (Resident #330) of 1 Resident reviewed for protection on electronic medical record. Findings include: A review of a facility policy titled, Confidentiality of Information and Personal Privacy, dated October 2017, indicated, Our facility will protect and safeguard resident confidentiality and personal privacy. The facility will safeguard the personal privacy and confidentiality of all resident personal and medical records. Assess to resident personal and medical records will be limited to authorized staff and business associates. A review of the Order Summary Report, indicated the facility admitted Resident #330 with diagnoses that included unspecified foreign body in bronchus causing asphyxiation, initial encounter, essential (primary) hypertension, other nonspecific abnormal finding of lung field. The 5-day Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/02/2024, revealed Resident #330 had a Brief Interview of Mental Status (BIMS) score of 12 which indicated the Resident was cognitively intact. During an observation on 06/03/2024 at 3:10 PM, The Surveyor observed a facility tablet screen showing Resident #330's electronic medical record (EMR). This was on top of the facilities treatment cart parked outside the Resident's room on the 500 hall. Visible on the screen for anyone in the hallway was: a. Facility name b. Resident ' s name c. Status d. Location e. Gender f. date of birth g. Age h. Physician i. Allergies j. Code status k. Special instructions l. Current Vital signs a. Blood Pressure b. Temperature c. Pulse d. Weight e. Respirations f. Blood sugar g. Pain m. Treatment to be performed n. Picture of Resident During an observation on 06/03/2024 at 3:25 PM, the surveyor observed staff, residents, and visitors pass the open EHR ( Electronic Health Record) in the hallway. During a concurrent observation and interview on 06/03/2024 at 3:29 PM, Surveyor observed a staff member exit Resident #330's room. Surveyor observed the staff member tap the tablet screen on top of the treatment cart which made the screen go white. Staff member identified as Licensed Practical Nurse (LPN) #17. LPN #17 was asked by the surveyor what was done to the tablet screen. LPN #17 stated, I hid it. I fixed it because I am about to walk away. Other staff members exited the room and this nurse walked away from surveyor and left the hallway. During a concurrent observation and interview on 06/03/2024 at 3:31 PM, staff member walked up to the cart and tablet in hallway and introduced self as Registered Nurse (RN) #6. When asked by the Surveyor, What should be done to the EMR in the hallway before entering a Resident's room? RN #6 stated, The computer should be turned off to not show the Residents EHR. It is due to [Health Information Portability and Accountability Act] HIPPA. During an interview on 06/05/2024 at 12:04 PM, the Director of Nursing (DON) was asked by the Surveyor, What should the nurses do in the hallway to the electronic medical record (EMR) on computers and tablets prior to leaving them unattended in the hallway? The DON replied, The lock screen should be put on for the resident's privacy. The Surveyor asked, What can be viewed while the lock screen is not in place while a tablet is on in the hallway with no staff present? The DON replied, Not much because the screen goes blank fast. The Surveyor asked how fast the screens go blank. The DON was unable to provide a set amount of time to when it goes blank. The Surveyor explained the tablet screen showing residents EHR was observed for 19 minutes and never went blank.

Based on observations, interviews, facility document review, and facility policy review it was determined the facility failed to ensure that portable oxygen cylinders were stored securely when not in use for the facility. Findings include: A review of a facility policy titled, Fire Safety and Prevention, dated May, indicated, Oxygen Safety: f. Store oxygen cylinders in racks with chains, sturdy portable carts, or approved stands. Never leave oxygen cylinders free-standing. During an observation on 06/04/2024 at 8:32 AM, Surveyor noted three oxygen cylinders in the 600 Hall therapy gym. Two cylinders were in a portable rolling stand. The third one was free-standing with a regulator in place. No staff around currently. During an observation on 06/04/2024 at 8:45 AM, Surveyor noted three oxygen cylinders in the 600-hall therapy gym. Two cylinders were in a portable rolling stand. The third one was free-standing with a regulator in place. Currently there are no staff in the therapy gym. During a concurrent observation and interview on 06/04/2024 at 9:03 AM, Speech Pathologist #15 confirmed there are three portable oxygen cylinders in the 600-hall therapy gym, two cylinders were in the portable rolling stand and the third is free-standing. Speech Pathologist #15 stated the oxygen is in the gym for residents in therapy that require oxygen usage. Speech Pathologist #15 stated that oxygen should be stored in the oxygen room, in bag on the back of the resident's wheelchair, or in a rolling oxygen cylinder carrier. Speech Pathologist #15 added these storage techniques are used to prevent the cylinder from falling over which could cause the cylinder to explode. During a concurrent observation and interview on 06/04/2024 at 09:09 AM, Licensed Practical Nurse (LPN) #16 confirmed there is three portable oxygen cylinders in the 600-hall therapy gym, two cylinders were in the portable rolling stand and the third one is free-standing. LPN #16 stated the free-standing cylinder is not secured or safe. When asked by the surveyor how portable oxygen should be stored. LPN #16 stated on the back of a resident's wheelchair in a bag, in a rolling oxygen cylinder carrier, or in oxygen storage room rack. LPN #16 added this is to ensure the tank does not tip over and possibly explode. During an interview on 06/04/2024 at 09:13 AM, the Director of Nursing (DON) was asked by the surveyor how portable oxygen cylinders are stored in the facility. The DON stated, In the back of the resident's wheelchair in bag holder, in oxygen rolling cart stand with wheels, or in a rack in the storage rooms on 200, 500, 600 halls. The DON did clarify all care staff transport oxygen in the facility. The surveyor asked, Why is oxygen not stored free-standing in the facility? The DON stated, To prevent the oxygen cylinders from falling over and to promote resident safety.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure that bathroom call lights had pull strings in place to accommodate the residents needs to call for help while in the bathroom for 4 of 15 resident bathrooms observed for call lights. Findings include: During the initial tour on 06/02/2024 from 10:46 AM through 11:34 AM, the 400-hall had four out 15 shared bathrooms that were identified as not having a call light string attached to the call light system for residents to call for assistance. 1. A review of the Order Summary Report, indicated the facility admitted Resident #7 with diagnoses that included cognitive communication deficit, repeated falls, muscle wasting, and dementia. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/03/2024, revealed Resident #7 had a Brief Interview of Mental Status (BIMS) score of 9 which indicated the resident had moderate cognitive impairment. The MDS indicated the resident required maximal assistance for toilet transfer and required moderate assistance for toilet hygiene. Further review of the MDS indicated the resident was continent of bowel. A review of Resident #7's care plan revealed the resident had an activity of daily living (ADL) self-care performance deficit related to weakness. The facility developed interventions to include the resident required extensive assistance of one staff for toileting, but the resident was noted to toilet self independently at times. The care plan also identified the resident was at risk for fall with an intervention to ensure the call light was in reach. During an observation on 06/02/2024 at 11:04 AM, Resident #7's bathroom had a white emergency call box with a red switch located on the wall next to the toilet. There was no pull cord present in the hole within the red switch that would allow for a resident to call for assistance if the resident were on the bathroom floor. During an observation on 06/02/2024 at 3:07 PM, Resident #7's bathroom had a white emergency call box with a red switch located on the wall next to the toilet. There was no pull cord present in the hole within the red switch that would allow a resident to call for assistance if the resident were on the bathroom floor. During an observation on 06/03/2024 at 3:02 PM, Resident #7's bathroom had a white emergency call box with a red switch located on the wall next to the toilet. There was no pull cord present in the hole within the red switch that would allow a resident to call for assistance if the resident were on the bathroom floor. During an interview on 06/04/2024 at 1:43 PM, Resident #7 stated the only way to call for help in the bathroom was to pull down the switch but can only do that if the resident was sitting on the toilet. Resident #7 expressed that if they needed help and weren't sitting on the toilet, the resident would have to yell and wait for help since there was no string present. During a concurrent observation and interview on 06/04/2024 at 1:58 PM, Certified Nursing Assistant (CNA) #18 stated if residents need assistance while in the bathroom, they pull the bathroom call light cord. CNA #18 stated if there is no cord present in the bathroom, staff should stay with the resident for resident safety and staff should notify maintenance via the maintenance log, which is located at each nurse's station. At this time, CNA #18 confirmed the there was no pull string in place in Resident #7's bathroom and that the switch was activated but not notifying staff. During a concurrent observation and interview on 06/04/2024 at 2:15 PM, Licensed Practical Nurse (LPN) #19 verified at the time of the observation there was no pull string in Resident #7's bathroom. LPN #19 stated that no resident should be left in the bathroom unattended and that with no pull cord present in Resident #7's bathroom, the resident was unable to notify staff when help was needed. LPN #19 stated missing call light pull strings should be reported via the maintenance log, which was located at each nurse's station. A review of the facility Maintenance Request was reviewed from 02/11/2024 through 06/04/2024 and there were no entries related to call light strings for 400 hall. During an interview on 06/04/2024 at 2:19 PM, the Maintenance Director confirmed he was not aware of any missing pull strings in the residents' bathrooms and that maintenance should be notified via maintenance logs located at each nurse's station. The Maintenance Director was holding a call light string and a battery and stated he was on his way to fix a nonworking bathroom call light and string in Resident #7's room. 2. During an observation on 06/02/2024 at 10:49 AM, the bathroom in room [ROOM NUMBER] had a white emergency call box with a red switch located on the wall next to the toilet. There was no pull cord present in the hole within the red switch that would allow a resident to call for assistance if the resident were on the bathroom floor. During an observation on 06/03/2024 at 2:58 PM, the bathroom in room [ROOM NUMBER] had the same observation of the emergency call box without a cord present. 3. During an observation on 06/02/2024 at 11:15 AM, the bathroom in room [ROOM NUMBER] had a white emergency call box with a red switch located on the wall next to the toilet. There was no pull cord present in the hole within the red switch that would allow a resident to call for assistance if the resident were on the bathroom floor. During an observation on 06/03/2024 at 3:09 PM, the bathroom in room [ROOM NUMBER] had the same observation of the emergency call box without a cord present. 4. During an observation on 06/02/2024 at 2:59 PM, the bathroom in room [ROOM NUMBER] had a white emergency call box with a red switch located on the wall next to the toilet. There was no pull cord present in the hole within the red switch that would allow a resident to call for assistance if the resident were on the bathroom floor. During an observation on 06/03/2024 at 3:00 PM, the bathroom in room [ROOM NUMBER] had the same observation of the emergency call box without a cord present. During an interview on 06/04/2024 at 2:24 PM, the Director of Nursing (DON) was asked, How do residents call for assistance while in the bathroom? The DON stated if a resident needed assistance while in the bathroom, staff were notified by the resident activating the call light via the pull string. The DON stated the importance of the call light string being in place in the bathroom was to be able to activate when assistance is needed. On 06/04/2024 at 03:01 PM, the Director of Nursing (DON) stated the facility did not have a policy for call lights.

Based on observations, interviews, facility document review, and facility policy review it was determined that the facility failed to ensure that a nurses wound treatment cart remained locked when left in the hallway without licensed staff remaining with the cart. Findings include: A review of a facility policy titled, Storage of Medications, dated April 2007, indicated, Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. During an observation on 06/03/2024 at 3:10 PM, the surveyor observed a 4-drawer cart on the 500-hall parked against the wall with the drawers facing the hallway. The bottom drawer was slightly open. No staff around the cart currently. The surveyor stayed near the cart and within short eyesight of the cart in the hallway. During an observation on 06/03/2024 at 03:25 PM, the surveyor observed staff, residents, and visitors pass the unlocked treatment cart in the hallway. During a concurrent observation and interview on 06/03/2024 at 3:29 PM, Surveyor observed a staff member exit a resident ' s room. Surveyor approached as the staff member pushed in a mechanism on the top right of the cart. Staff member identified as Licensed Practical Nurse (LPN) #17. LPN #17 was asked whose cart is this in the hallway? LPN #17 stated, This is the treatment nurse's cart. Surveyor asked, What did you do to the cart when you walked up to it. LPN #17 stated, I locked it, I fixed it because I am about to walk away from it. Other staff members exited the room and this nurse walked away from surveyor and left the hallway. During a concurrent observation and interview on 06/03/2024 at 3:31 PM, Staff member walked up to cart and introduced self as Registered Nurse (RN) #6. When asked by the surveyor, What should be done to the cart prior to leaving it in the hallway? RN #6 stated, It should be locked because there are supplies and medications in the cart. RN #6 also confirmed that with it unlocked anyone could get in the cart and take the medications or supplies. During the interview the following medications/supplies/cleaning agents were identified: a. A tube of silver silfadiazine b. Single use packages of zinc oxide formula c. Tube of medihoney gel d. Over 20 single use packs of triple antibiotic ointment e. A box of 25 single use packs of triple antibiotic ointment f. Approximately 32 individually wrapped povidone-iodine swabsticks g. A bottle of iodine cleaner h. A spray bottle of wound cleanser i. Multiple Petrolatum dressings j. Multiple Antimicrobial Silver Calcium Alginate Dressings k. Multiple Collagen Dressing with Silver l. Multiple Calcium Alginate Dressing with Antimicrobial Silver m. 5 bottles of prescription nystatin powder n. 3 bottles of Lotion o. Multiple packages of antimicrobial foam dressings p. A container of Germicidal Disposable Wipes q. 1 pair of bandage scissors During an interview on 06/05/2024 at 12:07 PM, the Director of Nursing (DON) was asked by the Surveyor how should a treatment cart be left in the hallway when unattended by licensed staff? The DON stated, They should be locked. The surveyor asked why the treatment cart should be locked? The DON replied, So anyone who wanted, or a resident going down the hallway could not get in the treatment cart.

Based on observation, record review, and interview the facility failed to ensure dietary staff washed their hands and changed their gloves before handling food items to prevent the potential for cross contamination for the residents who received meals from 1 of 1 kitchen; Hot food items were not maintained at or above 135 degrees Fahrenheit on the steam table while awaiting service to prevent potential food borne illness for the residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 127 residents who received meals from the Kitchen. The findings are: 1. On 06/02/24 at 10:30 AM, Dietary Aide (DA) #1 turned the sink on and washed her hands. She used her bare hands to turn off the faucet, contaminating her hands. Without washing her hands, she picked up plates, and placed them in the plate warmer and placed the bowls on a shelf with her fingers inside of them. 2. On 06/02/24 at 10:35 AM, DA #1 turned on the hand washing sink and washed her hands. She turned off the faucet with her bare hands, contaminating her hands. Without washing her hands, she picked up picked up glasses by their rims and placed them on the shelf close to the steam table. 3. 06/02/24 at 10:43 AM, the drawers below the counter where serving utensils were stored was rusty. 4. On 06/02/24 at 10:54 AM, a container of rice crisper was on a shelf in the storage room and was not fully covered, exposing it to air or other contamination. 5. 06/02/24 at 11:09 AM, DA #3 was wearing gloves on her hands, when she picked up a spray bottle from the cabinet and spread inside the pan. Contaminating the gloves. Without changing gloves and washing her hands, DA #3 removed biscuits from the box and placed them on the pans to be baked and served to the residents for noon meal. 6. On 06/02/24 11:17 AM, the following beverage containers on a shelf in the refrigerator were not covered, exposing them to cross contamination. a. A pitcher of tomato juice. b. A pitcher of cranberry juice. c. A pitcher of orange juice. d. An opened box of sausage. The box was not covered or sealed. e. An opened box of chicken. f. The were 2 boxes of coffee on a shelf with received date of 05/15 on it. The manufacture specification on the box documented, Keep Frozen. 7. On 06/02/24 at 11:20 AM, DA #1 turned on the hand washing sink and washed her hands. She turned off the faucet with her bare hands, contaminating her hands. Without washing her hands, she picked up individual napkins, placed utensils inside, and wrapped them for the residents to be used during the noon meal. When the surveyor asked DA #1 what the residents use the napkins for. DA #1 stated, to wipe their mouth when eating their meal. The surveyor asked DA#1 what should you have done after touching dirty objects and before handling clean equipment? DA #1 stated, I should have washed my hands. 8. On 06/02/24 at 11:25 AM, DA #2 used a 4-ounce spoon to place 21 servings of scalloped potatoes into a pan from a pan on the steam table, contaminating her hand. DA #2 then picked up a clean blade from a clean rack and placed it inside the blender, after that, DA #2 set the blender on the counter. Holding onto the metal bar attached to the blender motor, DA #2 pulled the motor towards the edge of the counter. Without washing her hands, DA #2 picked up the blade and attached it to the base of the blender to be used in pureeing food items to be served to the residents on pureed diets for noon meal. At 11:28 AM, the surveyor asked the DA #2 what should you have done after touching dirty objects and before handling clean equipment? DE #2 stated, I should have washed my hands. 9. On 06/02/24 at 11:31 AM, the following food items on a shelf in the walk-in freezer had no date when opened to ensure first in and first out. a. Two boxes of cookies. b. A box of broccoli. c. An opened of pork fritters was not covered or sealed. d. The floor in the walk-in freezer had an accumulation of sheet of ice on it. Dietary Manager #1 and #2 stated, Water comes from under the ground whenever it rains. 9. On 06/02/24 at 12:13 PM, the temperature of the food item on the steamtable was checked and read by DA #2 with the following results: Fried chicken 110 degrees Fahrenheit. The above meat items were not reheated before served to the residents. 10. On 06/02/24 12:28 PM, DA #2 was wearing gloves on her hands when turned on the stove, contaminating the gloves. Without washing her hands and changing gloves, untied the bread bag and used her contaminated gloved hand to remove slices of bread and placed them on the tray. She unzipped the plastic bag that contained slices of cheese, removed slices of cheese with her contaminated hand and placed them on top of the slices of bread to be used in making grilled cheese sandwiches to be served to the residents who asked for grill cheese sandwich with their meal. The surveyor immediately asked the Dietary Employee what you should do after touching dirty objects and before handling food items? DA #2 stated, I should have change gloves and washed my hands. 11. A facility policy titled, Employee Cleanliness and Handwashing Technique/Dietary department employees are required to wash their hands on the occasions listed below: Before beginning shift after picking up anything from the floor and any other time deemed necessary.

Based on record review, and interview, the facility failed to ensure the physician and family were notified after a resident had a change in condition, resulting in injury, for 1 (Resident #1) of 3 (Residents #1, #2 and #3) sampled residents. The findings are: On 09/20/23 at 9:06 a.m., the Surveyor asked Resident #1, Did you receive a chipped tooth from the lift? Resident #1 replied, Yes. The Surveyor asked, When did this happen? Resident #1 replied, A while ago. The Surveyor asked what happened. Resident #1 replied, The CNAs (Certified Nursing Assistants) were getting me up, and the bar hit my mouth, and chipped my tooth and it hurt. Resident #1 opened her mouth and a quarter of an inch of the left front tooth was broken off. The Surveyor asked what time of day this happened. Resident #1 replied, It was late morning, after breakfast, they were getting me up for lunch. The Surveyor asked if this had been reported. Resident #1 replied, I don't know. The Surveyor asked if she saw the dentist. Resident #1 replied, I did a few days ago. The Surveyor asked if staff rush when providing care. Resident #1 replied, I don't like the lift because I've been banged around so many times, and I'm picky, so it takes a while. Review of the Care Plan with a revision date of 09/03/21 noted Resident #1 required a mechanical lift with the assistance of two staff persons for transfers. A review of the Incidents by Incident Type documentation dated 03/20/23 through 09/20/23, provided by the DON on 09/20/23 at 7:43 a.m., did not include an incident for Resident #1 regarding a chipped tooth. A review of Resident #1's Progress Notes from 01/04/23 at 2:11 PM to 09/19/23 at 11:16 PM did not address an incident of Resident #1 chipping a tooth. A review of the Grievance Logs dated 06/01/23 through 08/31/23, provided by the Administrator on 09/20/23 at 8:12 a.m. did not include a grievance filed for Resident #1 regarding a chipped tooth. On 09/20/23 at 9:20 a.m., the Surveyor asked Licensed Practical Nurse (LPN) #1 how Resident #1 obtained a chipped tooth. LPN #1 replied, I heard about it four weeks ago, one of the CNAs told me, the bar on the lift swung and chipped [Resident #1's] tooth. The Surveyor asked what did you do about it after you found out. LPN #1 replied, I went and told the Social Worker, they usually are the ones who do the grievances, and I told the ADON [Assistant Director of Nursing]. The Surveyor asked if she filled out an Incident and Accident [I & A] form. LPN #1 replied, It didn't happen on my shift. I just heard about it and relayed the message to everyone. On 09/20/23 at 9:50 a.m., the Surveyor asked the Social Worker what the staff are supposed to do if a resident obtains an injury. The Social Worker replied, If a CNA, they notify the nurse, and the nurse will assess/evaluate the resident, notify the doctor, family, and dentist, start an I & A and notify the DON and Administrator. On 09/20/23 at 9:55 a.m., the Surveyor asked the ADON what the staff are supposed to do if a resident obtains an injury. The ADON replied, Report to the floor nurse, the nurse investigates and opens an I & A, message the physician, call the family. We discuss I & A interventions during stand-up meetings and try to prevent it from happening again. On 09/20/23 at 10:02 a.m., the Surveyor asked the DON what the staff are supposed to do if a resident obtains an injury. The DON replied, The CNA reports to the nurse, the nurse completes an I & A, after the I & A, I review the next day, it goes before the IDT [Interdisciplinary Team), and make sure interventions are in place. A policy titled, Accidents and Incidents - Investigating and Reporting, provided by the DON on 09/20/23 at 10:20 a.m. documented, .Policy Statement All accidents or incidents involving residents, employees, visitors, vendors, etc.[etcetera], occurring on our premises shall be investigated and reported to the Administrator. Policy Interpretation and Implementation 1. The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. 2. The following data, as applicable, shall be included . a. The date and time the accident or incident took place; b. The nature of the injury .; c. The circumstances surrounding the accident or incident; d. Where the accident or incident took place; e. The name(s) of witnesses and their accounts of the accident or incident; f. The injured person's account of the accident or incident; g. The time the injured person's Attending Physician was notified .; h. The date/time the injured person's family was notified and by whom; .5. The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall complete a Report of Incident/Accident form and submit the original to the Director of Nursing Services within 24 hours of the incident or accident. 6. The Director of Nursing shall ensure that the Administrator receives a copy of the Report of Incident/Accident form for each occurrence .

Based on observation, record review and interview, the facility failed to report an incident with injury involving 1 (Resident #1) of 3 (Residents #1, #2 and #3) sampled resident. The findings are: During an interview on 9/20/23 at 9:06 AM Resident #1 said her tooth was chipped when a bar from the lift swung and hit her mouth. The resident was not able to recall the date the incident happened and did not know if the incident was reported. Review of the Care Plan with a revision date of 09/03/21 noted Resident #1 required a mechanical lift with the assistance of two staff persons for transfers. A review of the Incidents by Incident Type documentation dated 03/20/23 through 09/20/23, did not include an incident for Resident #1 regarding a chipped tooth. A review of Resident #1's Progress Notes from 01/04/23 at 2:11 PM to 09/19/23 at 11:16 PM did not address an incident of Resident #1 chipping a tooth. A review of the Grievance Logs dated 06/01/23 through 08/31/23, did not include a grievance filed for Resident #1 regarding a chipped tooth. During an interview on 09/20/23 at 9:20 a.m., Licensed Practical Nurse (LPN) #1 said she heard about the incident four weeks ago. LPN #1 said she told the Social Worker and the ADON [Assistant Director of Nursing]. During an interview on 09/20/23 at 9:50 a.m., the Social Worker said she was unaware of Resident #1 broken tooth. The Social Worker said the CNA should notify the nurse if there is an injury, and the nurse should notify the doctor, family, and dentist, start an I&A and notify the DON and Administrator. During an interview on 9/20/2023 at 9:55 a.m., the Assistant Director of Nursing (ADON) said she was not aware of Resident #1 broken tooth and confirmed the nurse should have completed an I&A report which would be discussed during stand-up meetings. During a meeting on 09/20/23 at 10:02 a.m., the DON said she didn't know Resident #1 had a chipped tooth and confirmed there was not a grievance or I&A completed. A policy titled, Accidents and Incidents - Investigating and Reporting, provided by the DON on 09/20/23 at 10:20 a.m. documented, .Policy Statement All accidents or incidents involving residents, employees, visitors, vendors, etc.[etcetera], occurring on our premises shall be investigated and reported to the Administrator. Policy Interpretation and Implementation 1. The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident.5. The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall complete a Report of Incident/Accident form and submit the original to the Director of Nursing Services within 24 hours of the incident or accident. 6. The Director of Nursing shall ensure that the Administrator receives a copy of the Report of Incident/Accident form for each occurrence .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure proper placement of a gastrostomy tube was checked per Physicians' Orders prior to use for 1 (Resident #112) of 3 (#63, #93, and #112) sampled residents. The findings are: 1. Resident #112 was admitted on [DATE] with diagnoses of Dysphagia Following Cerebral Infarction and Moderate Protein-Calorie Malnutrition. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/19/23 documented a score of 9 (8-12 indicates moderately impaired) on the Brief Interview of Mental Status (BIMS). a. Review of Physician Order dated 02/22/23 documented, .Enteral Feed Order, Verify placement via aspiration and auscultation before med admin [medication administration], feeding/flushes . b. Review of Physician Order dated 05/09/23 documented, .Enteral Feed Order two times a day Bolus [named nutrition formula] 1.5 CAL 120ML [milliliters]. Flush With 60ML Before and After Bolus Feeding. 10 AM and 2PM (240 ml/360 CAL= shift) . c. On 05/09/23 at 10:00 AM, Licensed Practical Nurse (LPN) #1 administered tube feeding. LPN #1 failed to aspirate per Physicians' Orders. 2. On 05/11/23 at 8:25 AM, the Surveyor asked LPN #2 What should you do prior to administering enteral feedings? LPN #2 stated, Auscultate. The Surveyor asked, What could happen if Physicians' Orders to aspirate and auscultate are not followed? LPN #2 stated, It could not be in the right place. 3. On 05/11/23 at 8:31 AM, the Surveyor asked LPN #3 What should you do prior to administering enteral feedings? LPN #3 stated, Auscultation and aspiration. The Surveyor asked, What could if you do not aspirate the stomach contents prior to administering enteral feedings? LPN #3 stated, Could be in the wrong spot. 4. On 05/11/23 at 8:35 AM, the Surveyor asked LPN #4 What should you do prior to administering enteral feedings? LPN #4 stated, Auscultation and flush with water. The Surveyor asked, What could happen if you do not aspirate the stomach contents prior to infusing more nutrition? LPN #4 stated, If the Peg tube is out of place, it could mean, anything could go into the abdominal cavity. 5. On 05/11/23 at 8:40 AM, the Surveyor asked LPN #5, What should you do prior to administering enteral feedings? LPN #5 stated, Auscultate and aspirate. The Surveyor asked, What could happen if the Physicians' Orders to aspirate and auscultate are not followed? LPN #5 stated, It could go in the lungs and aspirate. 6. On 05/11/23 at 8:47 AM, the Surveyor asked LPN #6, What should you do prior to administering enteral feedings? LPN #6 stated, Auscultate. The Surveyor asked, What could happen if the Physicians' Orders to aspirate and auscultate are not followed? LPN #6 stated, You could place meds or liquids into the lungs. 7. On 05/11/23 at 9:02 AM, the Surveyor asked the Director of Nursing (DON), What do you expect the nurses to do prior to administering an enteral feeding? The DON replied, Either aspirate or auscultate. The Surveyor asked, What could happen if the Physicians' Orders to aspirate and auscultate are not followed? The DON stated, They could aspirate. 8. The facility policy titled, Enteral Feedings-Safety Precautions, provided by the DON on 05/11/23 at 10:15 AM documented, .Preventing aspiration, #2 Check gastric Residual volume as ordered .

Based on observation, record review, and interview, the facility failed to ensure that meals were served in a method that maintained the appearance of cold products and temperatures that were acceptable to the residents to improve palatability and encourage good nutritional intake during 1 of 1 meal observed. This failed practice had the potential to affect 22 residents who received meal trays in their rooms on the 100 Hall, 10 residents who received meal trays in their room on the 200 Hall, 18 residents who received meal trays on the 300 Hall, 21 residents who received meal trays in their room on the 400 hall, 7 residents who received meal trays in their room on the 500 Hall, and 16 residents who received meal trays in their room on the 600 Hall, as documented on a list provided by the Dietary Supervisor on 05/10/23 at 10:55 AM. The findings are: 1. Resident #72 had diagnoses of Fracture of Unspecified Carpal Bone, Left Wrist, Subsequent Encounter for Fracture with Routine Healing. Resident was independent with set up assistance for eating. a. On 05/08/23 at 2:55 PM, the Surveyor asked, How is the food here? Resident #72 stated, My only complaint is that the food is horrible, sometimes it is cold, and I have had to send my tomato soup to be warmed up. The oatmeal is so watery I must drink it. Breakfast is probably the coldest meal of the day. 2. Resident #98 was independent with set up for eating. a. On 05/08/23 at 12:50 PM, the Surveyor asked Resident #98 how the meals were. Resident #98 stated, Food is cold when it gets to us at the end of the line. They changed cooks so the food is better, but cold. 3. The following observations were made on the 100 Hall: a. On 05/09/23 at 1:25 PM, an unheated cart that contained trays for lunch, along with two other lunch trays on top of the food cart was delivered to the 100 Hall by CNA #4. At 1:37 PM immediately after the last resident received their tray in their room, the temperatures of the food items on the test tray were checked and read by CNA #4 with the following results: i. Salisbury steak with gravy was 113 degrees Fahrenheit. ii. Mashed potatoes was 106.2 degrees Fahrenheit. iii. Pureed Salisbury steak with gravy was 113.4 degrees Fahrenheit. iv. Peas were 102 degrees Fahrenheit. v. The Ice cream was melted. b. The Surveyor asked CNA #4 to describe the appearance of the ice cream served to the residents. She stated, It was melted. It was less consistency likely of ice cream. c. On 05/10/23 at 8:26 AM, an unheated cart that contained trays for breakfast was delivered to the 100 Hall by CNA #5. At 8:43 AM immediately after the last resident received their tray in their room, the temperatures of the food items on the test trays were checked and read by the CNA #5 with the following results: i. Milk was 57.9 degrees Fahrenheit. ii. Ground sausage with gravy was 105. 4 degrees Fahrenheit. iii. Scrambled eggs were 103. 6 degrees Fahrenheit. iv. Coffee was 126.9 degrees Fahrenheit. v. Pureed sausage was 101.8 degrees Fahrenheit. vi. Pureed scrambled eggs were 101.3 degrees Fahrenheit. vii. Pureed bread with milk was 98.2 degrees Fahrenheit. 4. On 05/09/23 at 1:00 PM, the cartons of ice cream served to the residents who received their meal trays on the 300 Hall Dining Room were melting. The Surveyor asked Certified Nursing Assistant (CNA) #1 who was assisting the residents in the 300 Hall Dining Room to describe the appearance of the ice cream. She stated, It was a little melted. 5. On 05/09/23 at 1:22 PM, the ice cream that was served to the residents on 400 Hall was melted. The Surveyor asked CNA #3 to describe the appearance of the ice cream served to the residents. She stated, It was melting.

Based on observation, record review, and interview, the facility failed to ensure that the foods stored in the freezer were covered and sealed to minimize the potential for food-borne illness for the residents who their received meals from 1 of 1 kitchen, dietary staff washed their hands between dirty and clean tasks, and before they handled clean equipment or food items to prevent potential for cross contamination. These failed practices had the potential to affect 127 residents who received meals from the kitchen (total census: 127), as documented on a list provided by Dietary Supervisor on 05/10/23 at 10:55 AM. The findings are: 1. On 05/08/23 between 11:30 AM and 12:54 PM, the following were observed in the kitchen: a. Dietary Employee #4 carried 2 stacks of glasses with the glasses against his shirt. b. Dietary Employee #3 held a cup by the top rim and was used it to scoop ice from the large ice machine. He turned and handed the ice filled cups to Dietary Employee #4 who held them by their rims to position for filling. c. A bag of bread, open to air, was on a shelf above the worktable next to the spices. d. Dietary Employee #5 was serving on the left side of the tray line. As he reached across the line for the items located on the far right, his clothing brushed the food items already on the plate. 2. On 05/09/23 at 12:35 PM, DE #1 pushed a cart towards the steam table. She picked up the tray cards and placed them on the trays. Without washing her hands, she picked up the cups that contained beverages by their rims and placed them on meal trays to be served to the residents for lunch. 3. On 05/09/23 at 12:36 PM, DE #2 picked up condiments, milk cartons, and cartons of supplements and placed them on the meal trays. Without washing his hands, he picked up cups that contained beverages and placed them on the meal trays to be served to the residents for lunch. At 1:49 PM, the Surveyor asked, What you should have done after touching dirty objects and before handling clean equipment? He stated, Washed my hands. 4. On 05/09/23 at 2:05 PM, a container of leftover cartons of ice cream from lunch was placed in the freezer. The Surveyor asked the Dietary Supervisor to describe the appearance of the ice cream. She stated,. They were melted. The Surveyor asked, How many cartons of ice cream were left in the container? The Dietary Supervisor counted them and stated, There were 5 cartons of vanilla ice cream, 10 cartons of chocolate ice cream and 34 cartons of strawberry ice cream. The Surveyor asked, Should melted ice cream be refrozen? She stated, No, they shouldn't have put them back in the freezer. We will throw them away. The Manufacturer's Instructions on the carton of ice cream documented, Keep Frozen. 5. On 05/09/23 at 4:26 PM, the following were observed in the walk-in freezer: a. Two opened and unsealed boxes of pie shells b. An opened and unsealed box of bread sticks c. An opened and unsealed box of biscuits d. An opened and unsealed box of hamburger patties e. An opened and unsealed box of pork fritters f. An opened and unsealed box of sausage g. An opened and unsealed box of carrots 6. The facility policy titled, Employee Cleanliness and Hand Washing Techniques, provided by the Dietary Supervisor on 05/10/23 at 10:55 AM documented, Dietary department employees are required to wash their hands on the occasions before beginning shift and any other time deemed necessary.

Based on observation, interview and record review, the facility failed to ensure fingernails were regularly trimmed and cleaned to promote good personal hygiene and grooming for 1 (Resident #35) of 16 (Residents #3, #20, #78, #71, #74, #82, #13, #39, #58, #98, #32, #2, #29, #5, #15 and #84) sampled residents who required assistance with nail care. This failed practice had the potential to affect 62 residents who required assistance with nail care, as documented on a list provided by the Director of Nursing on 1/12/22 at 11:16 a.m. The findings are: Resident #35 had diagnoses of Alzheimer's with Early Onset, Muscle Wasting and Atrophy and Anxiety Disorder. The admission Minimum Data Set with an Assessment Reference Date of 10/31/2021 documented the resident scored 12 (8-12 indicates moderately cognitively impaired) on a Brief Interview for Mental Status, required limited physical assistance of one person with personal hygiene and one person physical assistance with bathing. a. The Care Plan with a revision date of 11/10/21 documented, .The resident has an ADL [activities of daily living] self-care performance deficit . BATHING/SHOWERING: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse . b. On 1/10/22 at 11:11 a.m., Resident #35 was sitting in her room. Her toenails were long, extending over ½ inch past the tips of her toes. Resident #35 was asked, Do you like your toenails long? She stated, No, I like my fingernails a little long and fixed, but my toenails are too long and need to be trimmed. She was asked, Do you cut your own nails? She stated, No, they cut my nails. c. On 1/12/22 at 11:20 a.m., Resident #35 was lying on her bed in her room. Her toenails remained long, extending over ½ inch past the tips of her toes. d. On 1/11/22 at 3:30 p.m., Certified Nursing Assistant (CNA) #9 was asked, Who trims the resident's fingernails and toenails? He stated, The CNA at shower time is supposed to cut the residents' nails, unless they are diabetic, then the nurses cut their nails. e. On 1/12/22 at 2:10 p.m., Licensed Practical Nurse (LPN) #5 was asked, Who trims the resident's fingernails and toenails? She stated, Any of the RNs [Registered Nurses] or LPNs; if the CNA notifies the nurse, we try to do it right away. f. On 1/12/22 at 2:15 p.m., LPN #4 was asked, Who trims the residents' fingernails and toenails? She stated, Regular residents the CNAs or the nurses. If they are diabetic, only the nurses.

Based on observation, record review and interview, the facility failed to ensure medications were stored in a secure location the medication room on 1 (300 Hall Secured Unit) of 6 halls (100, 200, 300, 400, 500 and 600 Halls) to prevent potential tampering or access by cognitively impaired, self-mobile residents. This failed practice had the potential to affect 20 residents who resided on the 300 Hall, as documented on the Daily Census provided by the Administrator on 01/10/22 at 4:52 AM. The findings are: 1. A facility policy titled, Storage of Medications, provided by the Director of Nursing (DON) on 01/12/22 at 11:17 AM documented, .The facility shall store all drugs and biologicals in a safe, secure, and orderly manner . 7. Compartments (including but not limited to . rooms . containing drugs . shall be locked when not in use . 2. On 1/10/22 at 8:00 AM, the 300 Hall Medication Room door was ajar. A sign on the wall in the Medication Room documented, Please do not store meds [medications] in this med room, this is not a locked med room. A bottle of Miralax was on a shelf in the medication room. 3. On 01/10/22 at 8:03 AM, Licensed practical Nurse (LPN) #3 was asked, What is Miralax? She answered, It's a laxative. She was asked, Would that be considered a medication? She answered, Yes. She was asked, What could happen if a resident consumed too much Miralax? She answered, It would not be good. They could get dehydrated. She provided a bottle of Miralax from the medication cart. The label documented, .In case of overdose, get medical help or contact a Poison Control Center right away . 4. On 01/12/22 at 8:25 AM, LPN #5 was asked, What is Miralax? She answered, For constipation. She was asked, Would that be considered a medication? She answered, Yes. She was asked, What could happen if a resident consumed too much Miralax? She answered, They could have massive diarrhea and possible dehydration. 5. On 01/12/22 at 08:45 AM, the DON was asked, What is Miralax? She answered, It's for constipation. She was asked, Would that be considered a medication? She answered, Yes. She was asked, What could happen if a resident consumed too much Miralax? She answered, I don't know if there would be a negative outcome.

Based on observation, record review and interview, the facility failed to ensure the call light was operational to enable a resident to call for assistance when needed for 1 (Resident #98) of 9 (Residents #98, #75, #28, #15, #34, #422, #93, #76, and #64) sampled residents who were physically and cognitively able to utilize a call light. This failed practice had the potential to affect 29 residents who were cognitively and physically able to use a call light, as documented on a list provided by the Director of Nursing (DON) on 01/12/22 at 11:18 AM. The findings are: Resident #98 had diagnoses of Cerebral Infarction with Hemiplegia and Aphasia and Fractured Left Femur. The Quarterly Minimum Data Set with an Assessment Reference Date of 12/12/21 documented the resident scored 3 (0-7 indicates severely cognitively impaired) on a Brief Interview for Mental Status; required extensive physical assistance of two plus persons for bed mobility, transfers, dressing, and toilet use; and required extensive assistance of one person for personal hygiene. a. The Care Plan with a revision date of 10/25/21 documented, .The resident is high risk for falls r/t [related to] . HX [history] of CVA. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance . b. On 01/10/22 at 5:20 AM, Resident #98 was asked to push her call light. The call light was looped around the handle of a drawer on the bedside table and the resident could not reach it. This Surveyor attempted to activate Resident #98's call light for her, and the call light did not work. The light over the resident's door did not illuminate. The red light on the call light wall receptacle did not indicate activation. The scroll at the end of the hall did not indicate activation. No staff members responded. c. On 01/10/22 at 6:08 AM, the Medical Records Nurse was asked to activate the call light in Resident #98's room. The light over the resident's door did not activate. The red light on the call light wall receptacle did not indicate activation. The scroll at the end of the hall did not indicate activation. The Medical Records Nurse unplugged the cord from the receptacle on the wall and plugged it back in. She stated, It works now. d. On 01/10/22 at 8:09 AM, the Surveyor attempted to activate Resident #98's call light. The light over the resident's door did not activate. The red light on the call light wall receptacle did not indicate activation. The scroll at the end of the hall did not indicate activation. No staff members responded. e. On 01/11/22 at 7:45 AM, the Surveyor attempted to activate Resident #98's call light. The light over the resident's door did not activate. The red light on the call light wall receptacle did not indicate activation. The scroll at the end of the hall did not indicate activation. No staff members responded. f. On 01/11/22 at 7:55 AM, Certified Nursing Assistant (CNA) #7 was asked to activate Resident #98's call light. The red light on the call light wall receptacle did not indicate activation. She was asked, Does this call light work? She answered, No. If it worked, it would light up red. She was asked, Is this resident able to use a call light? She answered, Yes. g. On 01/11/22 at 8:05 AM, CNA #8 was asked, Is [Resident #98] able to use a call light? She answered, Yes. h. On 01/12/2021 at 9:07 AM, the DON was asked for a list of residents who were cognitively and/or physically able to use a call light. The DON stated, I don't think she's [Resident #98] able to use one. i. On 01/12/22 at 10:00 AM, the Maintenance Director was asked, Do you have a procedure for periodically checking call lights to ensure that they are working? He answered, The staff logs any maintenance issues in a book and when I get the notice, I fix it within 24 hours. He was asked, Has anyone given you a notice for any call lights on the 300 Hall? He answered, I got one yesterday . He was asked, If a light does not light up on the wall receptacle in the room, or over the door, or show up on the scroll in the hallway, would that mean the call light wasn't working? He answered, Yes. Unless someone deactivated it. j. On 01/12/22 at 11:18 AM, the DON provided a list of residents who were cognitively and/or physically able to use a call light and Resident #98 was not included on the list. She was asked to provide a policy for call light maintenance. She stated, We do not have a call light maintenance policy.

Based on observation, record review and interview, the facility failed to ensure a resident's bed linens were changed to provide a clean and comfortable environment and enhance the resident's quality of life for 1 (Resident #28) of 31 (Residents #1, #2, #3, #5, #6, #13, #15, #20, #26, #28, #29, #32, #34, #35, #39, #54, #58, #68, #71, #74, #75, #76, #78, #82, #84, #91, #93, #98, #114, #222 and #422) sampled residents who were dependent on staff for bed making The findings are: Resident #28 had diagnoses of Hypertensive Heart Disease with Heart Failure, Chronic Kidney Disease - Stage 5 and Muscle Wasting and Atrophy. The Quarterly Minimum Data Set with an Assessment Reference Date of 10/21/21 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status. a. An Order Listing Report dated 1/11/22 documented, [Resident #28] . Revision date 1/7/22 . Droplet isolation d/t [due to] COVID positive x [times] 10 days every shift until 1/12/2022 23:59 [11:59 p.m.] . b. On 01/11/22 at 10:30 AM, Resident #28 stated, They have not changed my sheets since I have been in this room [1/2/22]. Go ahead you can look and see, pull back the top cover and see them. There were 3 round, quarter-sized, dried, brown stains on the top sheet, close to the head of the bed. The resident stated See, I have not seen the aide all day today. c. On 01/11/22 at 3:40 PM, Certified Nursing Assistant (CNA) #11 was asked, How often do you assist [Resident #28] with her bath and how often do you change the bed linens? She stated, Oh, I help her with her bath whenever she needs it or asks for help and, as for the sheets, we change them anytime we help them with their baths. CNA #11 was asked if they had that on a task form. CNA #11 stated No, that is not on the task; we just do it. d. On 01/11/22 at 4:00 PM, Registered Nurse (RN) #2 was asked, How often are the bed linens to be changed for a resident? RN #2 stated, Oh, they are to do them every time they do the resident's bath or whenever they are dirty or soiled. e. On 01/12/22 at 10:00 AM, during the Resident Council meeting Residents #11, #56 and #64 stated The sheets are not being changed like they should. Don't care what they say they are doing; they are not doing it. f. On 01/12/22 at 11:55 AM, the Director of Nursing (DON) was asked, Who is responsible for changing the sheets for the residents? The DON stated, The CNAs are. The DON was asked, Who is responsible for making sure they are changed? The DON stated, Well that would be the charge nurse on duty at the time. The DON was asked, How does the charge nurse monitor that they are being changed? The DON stated, By observation of the residents' rooms. The DON was asked if there was a process, log, or policy regarding changing the residents' bed linens? The DON stated, No, we wouldn't have that. It is just done with the baths or whenever they are needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure residents were provided with the opportunity to participate in the development of their person-centered plans of care, to protect resident rights for 2 (Residents #93 and #76) of 2 sampled residents whose medical records were reviewed for participation in care planning. The findings are: 1. Resident #93 had diagnoses of Rhabdomyolysis, Type 2 Diabetes and Abnormalities of Gait and Mobility. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/9/21 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS), was independent in transfers, dressing, personal care, and toileting and required supervision with bathing. a. As of 1/10/22, there was no documentation in Resident #93's electronic medical record of any Care Plan meetings. b. On 1/10/22 at 10:30 a.m., Resident #93 was asked, Have you been attending your Care Plan meetings? He stated, I haven't been involved in any meetings about my care. c. On 1/11/22 at 3:20 p.m., the Director of Nursing was asked, Have you had a Care Plan meeting with [Resident #93]? She stated, I know we have talked with him, just guess it didn't get documented. 2. Resident #76 had diagnoses of Pyogenic Arthritis, Type 2 Diabetes and Non-[NAME] Leukemia. The Quarterly MDS with an ARD of 12/31/21 documented the resident scored 11 (8-12 indicates moderately cognitively impaired) on a BIMS, required extensive assistance with bed mobility, toileting and personal hygiene and was totally dependent for transfers. As of 1/10/22, there was no documentation in Resident #76's electronic medical record of any Care Plan meetings. 3. On 1/11/22 at 3:40 p.m., the MDS Coordinator was asked, Have you had a Care Plan meeting with [Resident #93]? She stated, Well no, not a formal meeting. I know we have talked with him, just didn't document it. She was asked, When you talked to him was it with yourself, nursing, dietary and the physician? She stated, Well, no but we have talked to him, and the physician is in the building twice a week. She was asked, Did you hold Care Plan meetings for [Resident #76]? She stated, I can't find where we had any. She was asked, How long has it been since you had a Care Plan meeting for this resident? She stated, Since his readmission in March.

Based on observation, record review and interview, the facility failed to ensure enteral tube feedings and water flushes were administered as ordered by the physician to maintain proper nutrition and hydration and formula and water containers were labeled as to their contents and date/time initiated to facilitate accuracy of enteral feedings and timely change-out of supplies for 1 (Resident #32) of 4 (Residents #32, #5, #84 and #20) sampled residents who had Physician's Order for enteral tube feedings. This failed practice had the potential to affect 4 residents who had a Physician's Order for enteral feedings and water flushes, as documented on a list provided by the Director of Nursing (DON) on 01/12/22 at 11:18 AM. The findings are: Resident #32 had a diagnosis of Dysphagia following Cerebral Infarction. The Quarterly Minimum Data Set with an Assessment Reference Date of 10/25/21 documented the resident scored 0 (0-7 indicates severely impaired) on a Brief Interview for Mental Status; had a feeding tube; and received 51% or more calories and 501 cubic centimeters (cc) per day or more of fluids via feeding tube. a. The January 2022 Physician Orders documented, .Enteral Feed Order every shift Jevity 1.5 Cal at 45 ml/hr [milliliters per hour] (25ml/hr H2O [Water] Flushes) . Order Date 07/24/2021 . Enteral Feed Order every shift Enteral Water Flush; with 60cc water before and after meds [medications] and feedings . Order Date 04/05/2021 . Enteral Feed Order every shift 25cc Water flush QHR [every hour] . Order Date 04/05/2021 . b. The Care Plan with a revision date of 08/03/2021 documented, .The resident requires tube feeding continuously r/t [related to] swallowing problem . The resident needs total assist x [times] 1 with tube feeding and water flushes. See MD [Medical Doctor] orders for current feeding orders . c. On 01/10/22 at 5:20 AM, Resident #32 was lying in bed. An enteral feeding pump was on a pole at the bedside. A bottle of Jevity 1.5 containing approximately 500 milliliters (ml) of formula was spiked and hanging on the pole. The water flush bag contained approximately 100 ml of water. Neither the formula bottle, nor the water flush bag were labeled with the date / time hung, the resident's name, and the contents. The pump was off, and the tubing was not connected at this time. d. On 01/10/22 at 7:50 AM, Resident #32's enteral feeding pump was turned off and the tubing was disconnected. Licensed Practical Nurse (LPN) #3 was asked, Why is she not receiving her enteral feeding? LPN #3 stated, She's hospice. I think we have orders to turn it off. Hospice Registered Nurse (RN) #1 was present on the hall. LPN #3 asked Hospice RN #1, Didn't you give orders to turn her pump off? Hospice RN #1 answered, No. That's why I asked you a while ago how long it had been turned off. LPN #3 entered Resident #32's room and, without changing the bottle of Jevity 1.5 or the tubing or filling the flush bag with water, she turned the pump on at 45 ml/hr. e. On 01/11/22 at 7:56 AM, Resident #32's enteral feeding pump was infusing at 45 ml/hr. A new top fill formula bag and free water flush bag were dated and labeled. LPN #3 was asked, What is the purpose for the label on the formula container? She answered, So we will know who it is for, the date it was hung and the rate. She was asked, When you turned the pump on yesterday morning, did you know when that bottle had been spiked? She answered, No. She was asked, If a resident has an order for tube feedings, should they receive the tube feedings as ordered? She answered, Yes. I thought it was on hold. f. On 01/13/22 at 8:35 AM, the DON was asked, Should a bottle of tube feeding formula be labeled? She answered, Yes, I already answered this. She was asked, Why should it be labeled? She answered, So you'll know their rate and all that information. Or you could look at the pump. She was asked, If the nurse is unsure of how long a bottle of formula has been hanging, and it is not being used, what should the nurse do? She answered, Throw it away. g. A facility policy titled, Enteral Tube Feeding via Continuous Pump, provided by the DON on 01/12/22 at 11:18 AM, documented, .Preparation 1. Verify that there is a Physician's Order for this procedure . General Guidelines 3. Check the enteral nutrition label against the order before administration. Check the following information: a. Resident's name, ID [identification] and room number; b. Type of formula; c. Date and time formula was prepared; d. Method (pump, gravity, syringe); and e. Rate of administration . Steps in Procedure . 5. Check the label on the enteral formula against the physician order formula . Initiate Feeding . 5. On the formula label document initials, date, and time the formula was hung/administered, and initial that the label was checked against the order . discard within 24 hours .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident #422 was admitted to the facility on [DATE] and had a diagnosis of Chronic Obstructive Pulmonary Disease and Emphysema. The admission MDS was not yet completed at the time of the survey. a. A Physician's order dated 01/04/22 documented, .OXYGEN @ 2Lpm [Liters per minute] via NC [Nasal Cannula] PRN every shift for Shortness of Breath . b. The Care Plan dated 01/04/22 documented, . The resident has altered respiratory status/difficulty breathing r/t COPD [Chronic Obstructive Pulmonary Disease], Emphysema .OXYGEN SETTINGS: O2 via NC @ 2 lpm prn with humidification as needed . c. On 1/10/22 at 8:07 AM and 10:39 AM and 1/11/22 at 8:35 AM, Resident #422 was lying in bed. She had oxygen in use at 2 liters per nasal cannula. There was no Oxygen in Use sign on the resident's door. d. On 01/12/22 at 8:55 AM, LPN #5 was asked, Does [Resident #422] use oxygen? LPN #5 stated, Yes she uses it, but not all the time. LPN #5 was asked, Is there a sign on [Resident #422's] door saying, 'Oxygen in Use'? LPN #5 looked at the door and stated, No, there is not. LPN #5 was asked, Should there be a sign on the door stating, 'Oxygen in Use'? LPN #5 stated, Yes there should be one. I am not sure how long she has been here. e. On 1/12/22 at 9:35AM, LPN #7 was asked, Should there be an Oxygen in Use sign on the door of a resident receiving oxygen? LPN #7 stated, Yes. LPN #7 was asked, Who is responsible for putting the Oxygen in Use sign on the resident's door? LPN #7 stated, Anyone, but probably the nurse. f. On 01/12/22 at 11:20 AM, the DON was asked, Should there be an Oxygen in Use sign on the door of a resident receiving oxygen? The DON stated, Yes. The DON was asked, Who is responsible for putting the Oxygen in Use sign on the resident's door? The DON stated, The nurse that applies the oxygen is responsible for putting the sign on the door. 4. A facility policy titled, Oxygen Administration, provided by the DON on 1/12/22 at 11:18 AM documented, .Verify that there is a physician's order for this procedure .The following equipment and supplies will be necessary . 'No Smoking/Oxygen in Use' signs .Place an 'Oxygen in Use' sign on the outside of the room entrance door . Adjust the oxygen delivery device so that .the proper flow of oxygen is being administered . Based on observation, record review and interview, the facility failed to ensure oxygen was administered at the flow rate ordered by the physician to prevent potential complications for 1 (Resident #32); resident, failed to ensure oxygen was administered only when ordered by a physician, to prevent potential complications for 1 (Resident #91); and failed to ensure an Oxygen in Use sign was posted to alert staff and visitors of the need for precautions for 1 (Resident #422) of 12 (Residents #91, #75, #78, #35, #28, #68, #32, #84, #39, #422, #74 and #82) sampled residents who received oxygen therapy. This failed practice had the potential to affect 30 residents who received oxygen therapy, as documented on a list provided by the Director of Nursing (DON) on 01/12/22 at 11:18 AM. The findings are: 1. Resident #32 had a diagnosis of Acute Respiratory Failure with Hypoxia. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/25/21 documented the resident scored 0 (0-7 indicates severely impaired) on a Brief Interview for Mental Status (BIMS) and did not receive oxygen therapy while a resident. a. A Physician's Order dated 07/15/21 documented, .Oxygen as needed for shortness of breath / comfort 2 liters/min [liters per minute] per nasal cannula PRN [as needed] . b. The Care Plan with a revision date of 08/03/2021 documented, .The resident has altered respiratory status / difficulty breathing r/t [related to] impaired lung exchange . Oxygen settings: O2 [oxygen] via nasal prongs @ [at] 2 per min PRN . c. On 01/10/22 at 7:36 AM, Resident #32 was lying in bed receiving oxygen by nasal cannula. The flow meter on the oxygen concentrator was set to 3 liters per minute. d. On 01/11/22 at 7:56 AM, Resident #32 was lying in bed receiving oxygen by nasal cannula. The flow meter on the oxygen concentrator was set to 3.5 liters per minute. e. On 01/12/22 at 8:15 AM, Licensed Practical Nurse (LPN) #4 was asked, If a resident has a physician's order for oxygen at 2 liters, should the concentrator be set on 3 liters? She answered, No. She was asked, Should it be set on 3.5 liters? She answered, No, it should be set on 2. f. On 01/12/22 at 8:25 AM, LPN # 5 was asked, If a resident has a physician's order for oxygen at 2 liters, should the concentrator be set on 3 liters? She answered, No. She was asked, Should it be set on 3.5 liters? She answered, No, it should be set on 2. g. On 01/12/22 at 8:45 AM, the DON was asked, If a resident has a physician's order for oxygen at 2 liters, should the concentrator be set on 3 liters? She answered, Technically, no. She was asked, Should it be set on 3.5 liters? She answered, No. 2. Resident #91 had diagnoses of Atrial Fibrillation, Heart Failure and Pleural Effusion, Not Elsewhere Classified. The Significant Change MDS with an ARD of 12/11/21 documented the resident scored 10 (8-12 indicates moderately cognitively impaired) on a BIMS and received oxygen therapy. a. The Care Plan dated as initiated 11/22/21 did not address oxygen therapy. b. The January 2022 Physician Orders did not document an order for oxygen. c. On 01/10/22 at 4:30 AM, Resident #91 was lying in bed with eyes closed receiving oxygen at 4 liters per minute via nasal cannula. d. On 1/10/2022 at 10:00a.m. Resident #91 was lying in bed with eyes closed receiving oxygen at 4 liters per minute via nasal cannula e. On 01/12/22 at 2:30 PM, the DON was asked, Should residents receiving oxygen have a physician's order? She stated, Yes, they should. She was asked, Do you know that [Resident #91] does not have a physician's order for oxygen? She stated, Let me look at it. The DON then pointed out where the oxygen tubing was mentioned in the Progress Notes but was unable to locate an order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure infection control measures and isolation precautions were implemented during a COVID-19 outbreak to prevent further potential spread of infection for 2 (Residents #1 and #15) of 26 (Residents #75, #78, #35, #28, #114, #68, #29, #98, #6, #5, #71, #32, #13, #84, #91, #34, #422, #93, #222, #3, #76, #74, #82, #58, #1 and #15) sampled residents; failed to ensure a thermometer utilized on multiple persons was sanitized between use during COVID screenings; and failed to ensure personnel conducting a COVID test donned the necessary personal protective equipment to prevent the potential spread of infection. The failed practices had the potential to affect all 131 residents who resided in the facility, per the Daily Census provided by the Administrator 1/10/22 at 4:41 AM, and all 163 staff members, as documented on a list provided by the Assistant Administrator on 01/12/22 at 8:43 AM. The findings are: 1. On 01/10/22 at 4:00 AM, the survey team arrived at the facility. Licensed Practical Nurse (LPN) #1 came to the door. The survey team was allowed entrance and directed to the kiosk to complete the COVID screening process. LPN #1 instructed the team that she would be taking temperatures manually due to the electronic system malfunctioning. LPN #1 presented with a temporal thermometer. She was not observed cleaning or sanitizing the thermometer prior to use. Thermometer was placed directly on the temple of the first surveyor and the temperature verbalized. LPN #1 did not clean or sanitize the thermometer prior to placing it on the temple of the second member of the survey team. LPN #1 completed the temperature screening process for all 7 members of the survey team. At no time was the thermometer cleaned or sanitized. On 01/10/22 at 11:47 AM, Certified Nursing Assistant (CNA) #10 was asked what the process was when using a reusable piece of medical equipment, such as a thermometer. She stated, .You wipe it before and after each use with an alcohol wipe. LPN #6 was asked the protocol when using a reusable piece of medical equipment such as a thermometer. She stated, .You should clean it before and after use with an alcohol wipe . 2. Resident #1, was admitted on [DATE] and had diagnoses of Dementia, Cerebral Infarction, Hemiplegia and Hemiparesis. a. A Physician's Order dated 01/03/22 documented, .CONTACT AND DROPLET ISOLATION RELATED TO POSSIBLE COVID EXPOSURE . b. The Closet Care Plan dated 01/03/22 documented, Isolation Precaution. c. On 01/10/22 at 4:10 AM, CNA #1 knocked on Resident #1's door, then entered the room. A Personal Protective Equipment (PPE) container was outside the door, and signage of Droplet and Contact Precautions was posted on the door. CNA #1 asked the resident what she wanted, grabbed the curtain, then turned off the call light. He sanitized his hands as he exited the room and closed the door. CNA #1 was asked, Is the resident on isolation? He replied, Yes. He was asked, What for? CNA #1 replied, I do not know. CNA #1 was asked, Should you sanitize your hands and don [put on] PPE as instructed on the signage before entering the resident's room? He replied, Yes. CNA #1 was asked, Why didn't you? He replied, Because I just went in to see what she wanted. 3. Resident #15 had a personal history of COVID-19 and received Hospice services. a. The Care Plan with a revision date of 10/21/21 documented, The resident has the potential to develop a respiratory infection due to the COVID-19 pandemic . The resident will not show signs/symptoms of respiratory infection through the review date . The resident has a history of testing positive for COVID-19. b. On 01/10/22 at 5:47 AM, CNA #2 entered Resident #15's room. There was a PPE container outside the door, and signage of Droplet and Contact Precaution was posted on the door. CNA #2 donned PPE knocked on the door, then grabbed a backpack from the floor, entered the room, and closed the door. c. On 01/10/22 at 5:53 AM, LPN #1, with an N95 mask on, stopped the medication cart at the entrance of Resident #15's room. She sanitized her hands, retrieved medication, placed one glove on, knocked on the door, entered the room, and touched the resident's bed and bedside table. With the ungloved hand, LPN #1 handed the medication to Resident #15, sanitized her hands, exited the room, and closed the door. LPN #1 was asked, Is the resident on isolation precautions? She stated, Yes. LPN #1 was asked, Should you don PPE before entering the resident's room? She stated, Yes. d. On 01/10/22 at 6:09 AM, CNA #2 exited Resident #15's room with her backpack. She ambulated to the 300 Hall, then entered the shower room. e. On 01/10/22 at 6:14 AM, CNA #2 exited the shower room. CNA #2 was asked, What do you carry in that backpack? She stated, Personal items, my work, personal cell phone and clear trash bags. CNA #2 was asked, Is [Resident #15] on isolation precautions? She stated, Yes. CNA #2 was asked, Should you bring your personal backpack in and out of an isolation room? She replied, No, I should not have. 4. On 01/10/22 at 9:14 AM, Social Director #2 was in his vehicle outside the front entrance. The Director of Nursing (DON) was standing next to the vehicle with a N-95 mask on, no other PPE. The DON swabbed the Social Worker through the car window, placed the swab in the card and entered the building. She left the swab/card in the Administrator's office, exited the office, then sanitized her hands. The DON was asked, When you were outside, were you testing a staff member for COVID? She replied, Yes. The DON was asked, Should you be wearing full PPE when testing staff for COVID-19? She stated, I guess so; he just asked if I could run out and test him. The DON was asked, What type of test did you perform? She replied, A rapid test. A copy of the test result was requested at this time. a. On 01/10/22 at 9:39 AM, a copy of Social Director #2's COVID-19 results was received from the DON and documented, Positive. b. On 01/11/22 at 11:39 AM, the DON was asked, Who is screened upon entering the facility? She replied, Everyone. She was asked, Who is trained on screening? She replied, Everyone. She was asked, When the electronic thermometer is not working what does the staff do? She stated, They use the temporal thermometer. The DON was asked, Should staff sanitize the thermometer between visitors/staff? The DON replied, Yes. The DON was asked, Why are [Resident #15] and [Resident #1] on Droplet and Contact Isolation? She replied, [Resident #15] is because she is unvaccinated and on reverse isolation due to the outbreak, and [Resident #1] is unvaccinated, a new admit, and now is on reverse isolation due to the outbreak. The DON was asked, When a resident is on Droplet and Contact Precautions, due to suspected, quarantined or positive COVID-19, should the staff don PPE before entering the resident's room? She replied, Yes. She was asked, When staff enters an isolation room, are they permitted to bring their personal backpack/items in and out of room? She stated, No. The DON was asked, Has the staff been educated/in-serviced on Isolation Precaution, and Personal Protective Equipment? She replied, Yes, multiple times. She was asked, Who is responsible to ensure staff are donning PPE when entering Isolation rooms? She replied, The charge nurse. 5. On 01/11/22 at 10:45 AM, the dirty side of the laundry room had lockers along the left side. Stacked on top of the lockers were pillows, piled as high as 4 tall. There were also multiple baskets of washable heel boots and positioning devices. A rack of donated clothes was hanging on a rack uncovered. Multiple boxes and bags of donated clothing were located directly on the floor. Upon entering the area where the washers were located, a shelving unit was located on the left side of the room. The top shelf contained multiple items including a baby doll, multiple washable heel boots and positioners. The second to the top shelf contained multiple pairs of shoes. A laundry employee was asked to clarify if these items were clean or dirty. She stated, They are clean . She was asked if they might be taken directly into the facility and given to or placed on a resident. She stated, Yes . She was asked if this area was the area where contaminated laundry was processed. She stated, Yes . She was asked, Do clothes come in in a red bag? The laundry employee denied the use of dissolvable laundry bags. She stated, .we open the red bags and then just put the clothes or the linens in the washer . She was asked to clarify the practice of storing clean items on the dirty side of the laundry facility. She stated, .I don't think it's good. A lot of that stuff belongs to therapy, and they won't come get it, so we have to put it somewhere . Multiple tubs of blankets, privacy curtains and donated clothing were observed sitting directly on the floor of the folding area of the laundry facility. 6. A facility policy titled, Policies and Practices - Infection Control, provided by the Administrator on 01/10/22 at 10:34 AM documented, The facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections.This facility's infection control policies and practices apply equally to all personal .residents, visitors . The objectives of our infection control policies and practices are to: Prevent, detect, investigate, and control infections in the facility .All personnel will be trained on our infection control policies and practices upon hire and periodically thereafter . Contact Precautions may be implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment . Droplet Precautions: Droplet Precautions may be implemented for an individual documented or suspected to be infected with microorganisms transmitted by droplets . Masks will be worn when entering the room. Gloves, gown, and goggles should be worn if there is risk of spraying respiratory secretions . 7. A facility policy titled, COVID-19 Testing Requirements for Staff and Residents, provided by the Administrator on 01/10/22 at 10:34 AM documented, This facility will test residents and staff . for COVID-19 based on parameters set forth by HHS [Department of Health and Human Services] secretary.Conducting the Test.Don appropriate PPE, which at a minimum includes gown, gloves, N95 mask preferred but surgical mask at minimum, eye protection .

Based on record review and interview, the facility failed to ensure residents and/or their family were notified by 5:00 PM the next calendar day following the occurrence of a confirmed positive case of COVID-19 for 1 (Resident #28) of 1 sampled resident and 1 staff who had tested positive on 1/2/22. This failed practice had the potential to affect 131 residents who resided in the facility, according to the Daily Census provided by the Administrator 1/10/22 at 4:41 AM. The findings are: Resident #28 had diagnoses of Hypertensive Heart Disease with Heart Failure, Chronic Kidney Disease, Stage 5, and COVID-19. The Quarterly Minimum Data Set with an Assessment Reference Date of 10/21/21 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status. a. A legal document dated 11/5/15 in the resident's medical record documented a family member as the resident's Power of Attorney. b. A Resident COVID-19 Testing form dated 1/2/22 documented the resident tested positive for COVID-19. c. A Communication Record dated 1/4/22 from the facility's COVID notification software documented a notification was sent on 1/4/22 at 3:15 PM by the Administrator and, .this is a message from [Facility], regarding: New COVID-19 Positive Resident. We wanted to make you aware, that we currently have 1 COVID-19 positive resident and 4 positive staff . d. The Progress Notes did not contain documentation the family was contacted by 5:00 p.m. the next day after the positive results were identified. e. On 1/12/22 at 8:38 AM, the Director of Nursing (DON) was asked, Who is responsible for notifying residents' family members of COVID-19 positive residents or staff in the nursing facility? The DON stated, That would be the Administrator I think, or maybe the Infection Preventionist. The DON was asked, Does she have access to the system to send the notices out after hours and on the weekends? She stated, I think she does; she should. f. On 01/12/22 at 8:45 AM, the DON was asked, Who is responsible for the activation of the electronic notification system? She called the Infection Control Nurse to confirm the Administrator was responsible for notification of families. The DON was asked, Who is responsible for notification of employees when there are positive COVID cases in the facility? The DON and Infection Preventionist discussed who was responsible, then the Infection Preventionist stated, .I'm not sure there is a formal way that employees are notified . g. On 1/12/22 at 9:10 AM, the Human Resources Director was asked how employees were notified when there was a positive COVID case in the building of either staff or resident. She stated, .each department manager sends a text to their employees to let them know . h. On 1/12/22 at 8:55 AM, the Assistant Administrator was asked, If a family has been notified by phone by staff, where would it be in the resident's file? She stated, If one was done, it would be under Progress Notes in the file. The Assistant Administrator was asked to provide a copy of the Progress Note for the notification of Resident #28's positive COVID-19 results for 1/2/22 or 1/3/22. i. On 1/12/22 at 11:50 AM, the Assistant Administrator stated, Could not locate a note in [Resident #28's] file regarding the family being notified of the positive COVID-19 results. Only the [COVID notification software notification] that was sent out on 1/4/22. The Assistant Administrator was asked, Who notifies the Administrator of a COVID-19 positive resident or staff? She stated, Whoever is performing the test, which is the nursing staff generally. The Assistant Administrator was asked, Who is back up for the Administrator for getting COVID-19 positive calls and responsible for sending out the notices if she is unavailable? She stated, Oh, that is me. I am. She was asked, How are the staff notified of a positive COVID-19 case in the nursing facility? The Assistant Administrator stated, We use a Notification Posting Form, and it is placed up in the facility for the staff to see. j. The January 2021 lists of COVID-19 positive residents and staff, provided by the DON on 1/12/22 at 8:45 AM, documented 3 residents (1 resident tested positive on 1/2/22 and 2 tested positive on 1/7/22) and 16 staff members tested positive, with the first testing positive on 1/2/22 and the most recent testing positive 1/11/22. k. On 1/12/22 at 11:00 AM, the Electronic Medical Record documented the last recorded notification by the facility's COVID notification software was sent out on 1/8/22. The facility had new positive cases on 1/9/22 and 1/10/22, and no notification had been sent to family and or representatives.

Based on observation, record review and interview, the facility failed to ensure food was served at temperatures that were acceptable to the residents, to improve palatability and encourage good nutritional intake during 1 of 2 meals observed. This failed practice had the potential to affect residents who received meals in their rooms, including 24 residents on the 100 hall, 14 residents on the 200 Hall, 19 residents on the 300 hall, 28 residents on the 400 hall, 9 residents on the 500 hall, and 13 residents on the 600 Hall, as documented on a list provided by Dietary Supervisor on 01/10/22 at 2:40 PM. The findings are: 1. On 01/10/22 at 8:16 AM, an unheated cart with 24 breakfast trays was delivered to 600 Hall by Certified Nursing Assistant #1. At 8:36 AM, immediately after the last meal tray was served on the 600 Hall, the temperatures of the food items on a test tray from the cart were checked and read by Certified Nursing Assistant (CNA) #1 with the following results: a. Pureed eggs - 109 degrees Fahrenheit. b. Cream of Wheat - 106 degrees Fahrenheit. c. Sausage links - 101.8 degrees Fahrenheit. d. Pureed sausage - 102.2 degrees Fahrenheit. e. Scrambled eggs - 108 degrees Fahrenheit. f. Oatmeal - 102.4 degrees Fahrenheit. g. Pureed bread with milk - 102 degrees Fahrenheit. 2. On 01/10/22 at 8:42 AM, an unheated cart with 20 breakfast trays was delivered to 400 Hall by CNA #2. There were 2 breakfast trays on top of the cart. At 9:04 AM CNA #2 took one of the breakfast trays from the top of the food cart to deliver to a resident. She was asked to check the temperature of the food items. The temperature of the milk was 48.7 degrees Fahrenheit. CNA #2 left to attend to the resident and License Practical Nurse (LPN) #1 finished checking the temperatures of the food items on the tray. The temperatures of the food items were as follows: a. Milk - 48.7 degrees Fahrenheit. b. Sausage links - 90. 5 degrees Fahrenheit. c. Scrambled eggs - 80 degrees Fahrenheit 3. On 01/10/22 at 9:07 AM, immediately after the last resident received a tray in their room on the 400 Hall, the temperature of the food items on a test tray from the cart were checked and read by LPN #2 with the following results: a. Milk - 50 degrees Fahrenheit. b. Sausage links - 91.4 degrees Fahrenheit. c. Scrambled eggs - 81 degrees Fahrenheit. d. Ground sausage - 101.2 degrees Fahrenheit. e. Oatmeal 113 - degrees Fahrenheit 4. On 01/10/22 at 8:48 AM, a utility cart that contained 6 trays for breakfast was delivered to the 400 Hall by CNA #3. At 9:18 AM, immediately after the last resident received a tray in their room on the 400 Hall, the temperature of the food items on a test tray from the utility cart were checked and read by LPN #1 with the following results: a. Scrambled eggs - 109 degrees Fahrenheit. b. Cream of Wheat - 101 degrees Fahrenheit. c. Oatmeal - 101.3 degrees Fahrenheit. d. Ground sausage links - 93.7 degrees Fahrenheit. e. Pureed eggs - 95.6 degrees Fahrenheit. f. Pureed sausage - 95.9 degrees Fahrenheit. g. Pureed bread with milk - 98.4 degrees Fahrenheit. h. The ice cream was melted. At 9:20 AM, LPN #1 was asked to describe the appearance of the food and stated, .ice cream was melted. 5. On 01/10/22 at 9:21 AM, the Assistant Director of Nursing was asked about the temperature of the food items served to the residents. She stated, It could have been higher. I feel like it's cold. 6. On 1/10/22 at 9:26 AM, CNA #2 was asked about the temperature of the food items served to the residents. She stated, It was a bit cold. I was the only one passing out trays. 7. On 01/10/22 at 9:57 AM, Resident #222's daughter was present in the resident's room. When asked about the food provided, the daughter stated, .we have been working on that . She stated the food was cold.

Based on observation and interview, the facility failed to ensure foods stored in the storage area, refrigerator and freezer were sealed, labeled and dated; the kitchen and dry storage area floors, walls, baseboards, equipment / appliances, ice machine, and air vents were maintained in clean condition; expired food items were promptly removed from stock and discarded; leftovers were promptly utilized or discarded; and dietary staff washed their hands before handling clean equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 129 residents who received meals from the kitchen (Total Census: 131), as documented on a list provided by the Dietary Supervisor on 01/10/2022. The findings are: 1. On 01/10/2021 at 4:03 AM, the following observations were made in the kitchen: a. An open bag of gravy was on a shelf above the food preparation counter. The bag was not sealed. b. A can opener attached at the end of the food preparation counter had shaving metal on the blade. c. A 64 ounce opened bottle of prune juice was on a counter. The manufacturer's specifications on the bottle documented, Refrigerate after opening. 2. On 01/10/22 at 4:21 AM, the following observations were made in the kitchen: a. There were 4 bags of hamburger buns with an expiration date of 12/24/2021. b. An uncovered open box of quick creamy wheat was on a shelf in the storage room. c. An uncovered open box of baking soda was on a shelf above the food preparation counter. 3. On 1/10/22 at 4:32 AM, an open box of sausage links was on a shelf in the walk-in refrigerator. The box was not covered. 4. On 01/10/22 at 4:33 AM, the following observations were made in the walk-in freezer: a. An open box of rolls was not covered or sealed. b. An open box of pork loin fritters was not covered or sealed. 5. On 01/10/22 at 4:41 AM, the ice machine in the receiving area had a wet black residue on the interior panel. Dietary Employee #1 was asked to wipe the black residue on the interior panel of the ice machine. She did so, and the black residue easily transferred to the tissue. She was asked, How often do you clean the ice machine? She stated, I am not sure. At 7:44 AM, the Dietary Supervisor was asked, How often do you clean the ice machine? She stated, Once a month and as needed. She was asked, Who uses the ice from the ice machine. She stated, That's the ice the CNAs [Certified Nursing Assistants] use for the water pitchers in the residents' rooms, and we use it in the kitchen to fill beverages served to the residents at meals. Everybody uses it now. 6. On 01/10/22 at 4:44 AM, the cabinet below the deep fryer had an accumulation of caked-on, black, greasy residue, dirt, and debris at the bottom of it. Dietary Employee #1 was asked to describe what was found inside the cabinet below the deep fryer. She stated, Grease with a build-up of crumbs. She was asked, How often do you clean it? She stated, They usually clean it every Friday. She was asked, Does it look like it has been cleaned every Friday? She stated, No. It doesn't. 7. On 01/10/22 at 5:05 AM, the following observations were made in the kitchen area: a. A thick black residue was sticking out of the two ceiling vents above the food preparation area b. The floor and the corners throughout the kitchen were stained. Loose food items, butter, and pepper packages were on the floor. c. There were 9 missing tiles below the food preparation sink. The floor by the door leading to the walk-in refrigerator/freezer was chipped. d. The baseboard by the hand washing sink was loose. e. The motor behind the conventional oven had buildup of greasy residue on it. 8. On 01/10/22 at 5:11 AM, Dietary Employee #2 was wearing gloves when she pushed a cart towards the counter, contaminating the gloves. Without changing gloves and washing her hands, she removed paper cups by the rims from the bag and placed them on the trays. She then poured beverages in the cups to be served to the residents for breakfast meal. 9. On 1/10/22 at 5:32 AM, Dietary Employee #4 turned on the sink faucet and rinsed tomatoes. She then turned off the sink faucet and placed the tomatoes on the cutting board, contaminating her gloves. Without changing gloves and washing her hands, she removed shredded lettuce from the bag and placed it in individual bowls. She cut tomatoes using the cutting board. She then placed the tomatoes on top of the lettuce to serve to the residents who requested salad with their lunch meal. Dietary Employee #4 was asked, What should you have done after touching dirty objects and before handling clean equipment or food items? She stated, Change gloves and wash my hands. 10. On 01/10/22 at 5:33 AM, Dietary Employee #3 was wearing gloves when she picked up boxes of thickened cranberry juice, apple juice, dairy, water, sweetened tea and orange juice and placed them on the counter, contaminating her gloved hands. Without changing gloves and washing her hands, she picked up cups by the rims and placed them on the trays and poured beverages to be served to the residents on thickened liquids for the breakfast meal. At 6:20 AM, Dietary Employee #3 was asked, What should you have done after touching dirty objects and before handling clean equipment or food items? She stated, Change gloves and wash my hands before picking up the cups. 11. On 01/11/22 at 7:54 AM, the following observations were made in the refrigerator in the unit on 300 Hall: a. Water with a brown substance was standing in the bottom of the refrigerator. b. A tan substance was on the shelves and walls of the refrigerator. c. A carton of whole milk was on a shelf in the refrigerator with an expiration date of 1/8/2022. d. A zip lock bag of cheese slices was on a shelf in the refrigerator. The bag had no date on it. e. A white Styrofoam container was on a shelf in the refrigerator with and contained an unidentified item. The container was not labeled or dated. f. Five cartons of health shakes were in a bin in the refrigerator with no date on them. g. Two containers of melted raspberry ice cream and a container of melted vanilla ice cream were in the door of the refrigerator. 12. A facility policy titled, Employee Cleanliness and Handwashing Technique, provided by the Dietary Supervisor on 01/10/22 at 2:09 PM, documented, Dietary department employees are required to wash their hands on the occasions listed below: .f. after disposing or handling of trash or food. g. after handling dirty dishes h. after handling raw poultry, meat or eggs, i. after picking up anything on the floor j. any other time deemed necessary .