Based on observation, interview and record review, the facility failed to ensure that foods are store, prepare, distribute, and serve food in accordance with professional standards for food service safety in one of one kitchen in that. The facility failed to ensure that foods were sealed, labeled, and dated. The facility failed to ensure that equipment was cleaned and in good operating condition. The facility failed to ensure that kitchen floors were cleaned. The facility failed to ensure that plates with dried food particles were not stored with clean plates. The facility failed to ensure that chipped plates were not stored with unchipped plates. The facility failed to ensure that menu items on the steam table was maintained at 135 degrees F and above. The facility failed to ensure the expired food was not stored with foods that are not expired. The facility failed to ensure that groceries received were not store directly on the floor. The facility failed to ensure that the dish machine had soap and was sanitizing at the proper PPM. An Immediate Jeopardy (IJ) situation was determined to have existed on 04/ 12/2023 at 10:38am. While the IJ was removed on 04/25/2023 at 5:26PM, the facility remained out of compliance at actual harm with the potential for more than minimal harm that is not immediate jeopardy and a scope of a pattern due to the facility's needs to evaluate the effectiveness of the corrective systems. These failures affected all residents who ate foods prepared by the kitchen and placed them at risk of foodborne disease and other illness. Findings included: Observations of the kitchen on 4/8/2023 at 11:00am revealed the following: A bag of onions, and rice and a box of iced tea, were noted directly on the floor. There were undated, unlabeled cookies in a plain zip loc bag, rice, pasta, and frosted flakes. There were containers with rice, and flour opened that were not labeled or dated. Observation of the kitchen floor on 4/8/2023 at 11:05am revealed debris, particles of food, utensils on the kitchen floor. Observation of the refrigerators and freezer in the kitchen on 4/8/2023 at 11:08am revealed the following: A container of eggs, with a used by date of 4/7/23. There were containers in the refrigerator that appears to be peaches, one appears to be macaroni and cheese, and sliced meat, that were open, unlabeled, and undated. There was an open sliced cheese not labeled or dated. There was a box with chicken with liquid residue spilling in the refrigerator not labeled or dated and contaminating other food items. There was an open carton of scrambled open carton and undated. There were missing shelfs from the freezers. Observations of the kitchen on 4/9/2023 at 10:20am revealed the following: Debris was noted on the floor. The three-compartment sink was full of dirty dishes, steam table had an accumulation of burnt food particles in the wells and on the top. The sneeze guard had dried food particles on it. The grill has an accumulation of dried food particles on it and the stove had burnt food particles on it. Observation on 4/9/2023 at 2:00pm of the refrigerator in the kitchen opposite the steam table revealed a box of molded rotten tomatoes, one bag of parsley and five bags of spinach with black liquid in the bags. Observation of the facility's kitchen on 4/10/2023 between 10:45am and 12:00pm revealed the following: The hand washing sink beside the grill had brown stains all over it. The grill had an accumulation of burnt food particles on it. The stove top and had burnt food particles and grease on it, the inside of the oven had burnt food particles and grease. The sides of the deep fat fryer and the stove had dried food on them. The grill had an accumulation of burnt food particles on the surface and back splash. The wells of the steam table were black from burnt food particles and the water in the wells was brown. The sneeze guards had dried food particles on them. The shelf under the steam table had food stains and food particles on it. The floor of the kitchen had excess debris on it, food spillage and dirt. Observation on 4/10/2023 at 12:05pm of the operation of the dish machine by Dietary Aide C revealed the litmus paper did not change color on testing to ensure that the dishes were sanitized. Further observation revealed there was no soap in the container that was attached to the dish machine. Dishes from breakfast was observed on the trolley in the dining room not washed. Pots and pans from breakfast were still in the three compartments sink not washed. In an interview with Dietary Aide C on 4/10/2023 at 12:10 she said she was called in to assist the cook because the schedule aide had called in and that was why the dishes were not cleaned. She said they were short staffed. She stated she washed some dishes utilizing the dishwasher that morning. She stated she was not trained on using the dishwasher and she only knew how to turn it on. She stated that if dishes that were not washed properly it could cause residents to get sick due to cross contamination. Observation of the dishwasher on 4/10/2023 at 12:10pm revealed there were two buckets one with liquid soap and liquid sanitizer. The bucket with the soap was crystallized. The tubing from the sanitizer to the dish machine was clogged. Surveyor determined it was clogged/ tubing was not working due to testing the dishwasher for sanitizer with litmus paper and it did not change color which would indicate sanitizer was not being used or getting through the tubing. Observation of the dry storage room on 4/10/23 at 1:00pm revealed the following: Macaroni, breadcrumbs, rice crispy, corn flakes in plain plastic open not labeled and dated. Grocery was stored directly on the floor not on pallets. Further observation on 4/10/2023 at 1:05pm of the free-standing freezer revealed cookie dough and hash brown open not sealed. Observation of the kitchen's steam table on 4/10/2023 at 1:55pm revealed the following menu items were not at the correct holding temperature: The menu items were green peas at 125 degrees F., chopped pork at 99 degrees F., Pureed peas at 123 degrees F., and Pureed pork meat at 120 degrees F. The surveyor observed Dietary Aide C about to plate items from the steam table. In an interview with [NAME] D on 4/10/2023 at 1:57 pm he said the reheating was 120 degrees Fahrenheit. At that time, he was asked by the Surveyor if he was in-service on food temperature he said No. The surveyor at that time inform him the menu items needed to be reheated to the correct reheating temperature of 165 degrees Fahrenheit. Observation of meal service on 4/10/23 at 1:59pm revealed Dietary Aide C removed the food items and reheat them to 165 degrees Fahrenheit after being prompted by the surveyor. Observation on 4/10/2023 at 2:00pm revealed chipped plates stored with unchipped plates. The divided plates had dried food particles in them. The plates were pointed out to Dietary Aide C, and she discarded the chipped plates and return the divided plates to the dish room to be rewashed. Interview on 4/10/2023 at 2:00pm with Dietary Aide C she said that when dishes were washed, they should check them to ensure they were clean and not chipped before they were stored. This she said could prevent cross contamination. In an interview with the Dietician on 4/11/2023 at 12:45pm she stated she comes to the facility once month typically on the 3rd week of the month. She stated at that time she reviews the menu, ask for a test tray, and audits the kitchen. She stated the last audit of the kitchen was 3/28/2023. She stated prior to exiting the facility she reviews the sanitation audit with the administrator in detail and discusses concerns. She stated she follows up the next time she was in the facility. She stated she met with the administrator on 3/28/2023 and discussed the sanitation audit report with the administrator. She stated that the administrator should have addressed the concerns noted in the document. She stated if the dishes were not sanitized it could cause an increased risk of food borne illness. She stated that food that were not properly stored, labeled, and dated could pose a risk to residents as they can consume food that were expired or spoiled which can pose an increased risk of food borne illness. In interview with RVP on 4/11/2023 at 12:00pm, she said that the administrator oversees the facility, and the kitchen as much as she can. She said she received the sanitation report via email, but she did review the sanitation report. She had not been in the kitchen, only to the door. She reported It's between the dietician and the administrator when they review the sanitation report, they discuss how they would solve the issue. She can't confirm what the issues were in March regarding the sanitation report. She stated Administrator oversees the overall operation of the facility. She said she did not expect to be told everything that goes on in the building as that was not her role, as she was the consultant. She said the administrator was the top of the chain at the facility, and she does not overstep her position. She stated she believed the facility was running well but based on this interview she would agree the system the administrator was using was not working. In an interview with Administrator on 4/11/2023 at 2:00pm, she stated a Dietary manager was hired but has not yet started. She stated the facility has been without a dietary manager since the beginning of March 2023. She stated on Thursday 4/6/2023 she did rounds in the kitchen and observed the cleanliness, food storage but did not take an inventory. She stated on 4/6/2023 the kitchen was clean, and all items were labeled and dated. She stated human resources did rounds on Friday 4/7/2023 in the kitchen as well as ensuring it was clean and food items were stored correctly. She stated she would expect the kitchen to get dirty during service and cleaned daily. She stated that she did not keep a log of her kitchen audits because it was not a regulation. She stated that her audits are by pop ins and the area she audits varies. She stated she reviewed the sanitation report with the dietician and corrected all the issues. She stated she did go a little low on emergency food supply and she ordered more foods on 4/10/2023. She stated the kitchen currently has adequate shelving. She said the can opener was cleaned off because it was a little dirty and she did not purchase a new one. She stated if the kitchen is unsanitary, it can pose a risk to resident's health and safety due to cross contamination. She said if certain meats were not kept at the right temperature, that could cause residents to get sick. She stated that foods that are not dated or labeled can cause the kitchen staff not able to determine the correct best used by dates. She stated she could not answer to whether everything was dated, labeled and in accordance with professional standards of food service because she had not been back there that day. She stated if dishes were not being sanitized correctly it could cause cross contaminated. In an interview with Human Resource L on 4/12/2023 at 10:00am, she stated she did not complete rounds in the kitchen and that would be the responsibility of the administrator. She stated she did not complete rounds in the kitchen on 4/7/2023. Observation on 4/16/2023 between 4:45pm and 6:00pm revealed the following: Dirty dishes were noted in the dining room and on the hallway. Three compartment sinks were filled with dirty pans and baking sheets. The kitchen floors had debris, food particles and food spillage. Two dirty plates were observed on the dining table from lunch at 5:00pm. The sneeze guard had dried food particles on it. In an interview on 4/16/2023 at 5:00pm with Dietary Aide G she said that [NAME] C was the only one working that morning as the aide who was schedule had called in. She said [NAME] D came in later that morning. She said everything was late and as a result the dishes were not cleaned, and she had to use disposables. She said she came in for her regular shift and was doing her duties. She stated that the three compartment sink was not used to wash or sanitize dishes from breakfast. In an interview on 4/16/2023 [NAME] D at 6:15pm he stated that the Aide for the morning shift had called in and the cook had to work by himself until he got to work at about 10:30am that morning. He said because he had to help [NAME] A to set up and get lunch ready, he was behind and did not get a change to clean up. He said he was going to clean the kitchen up and wash the dishes before he leaves that day. In an interview with the RVP on 4/17/2023 at 11:30 she said that there was some breakdown in communication and that was why it took longer than usual to get help that morning. She said the Aide said she send a text and the current management team was not on that text and did not receive the text as a result they were not notified. She said they were unable to get help in a timely manner. She said they were looking at another method of communicating that would include management staff. Observation of the steam table on 4/21/2023 at 12:30pm revealed [NAME] E sharing lunch. He opens the cooler and without changing his gloves he started plating the food. He took up the breadstick and bend it in half and placed it on the resident's plate. He also used the same gloved hands to fix the food on the tray. An interview was attempted on 4/21/2022 at 12:35pm with the [NAME] E but he did not respond when he was asked about changing his gloves. At that point he changed his gloves. The Dietary manager at that point discarded the food gave him tong to pick up the breadstick. The Dietary Manager told him at that time to use a tong to pick up ready to eat foods. Observation of the kitchen on 4/24/2023 at 2:45pm revealed the stove was not cleaned it had an accumulation of dried food particles on the stove top. The Oven had an accumulation of grease and burnt food particles on the inside. Grill has an accumulation of grease and burnt to the back splash. Observation of the storage room on 4/24/2023 at 2:55pm revealed foods in the Free-standing freezer were not labeled and dated: A plain plastic bag with steak fries not labeled or dated A box with Folded cheese omelets was opened and not sealed. A box with beef patties opened and not sealed. Fish patties and Pepperoni were in plain plastic bags, and they were not labeled or dated. Observation on 4/24/2023 at 3:04pm of the refrigerator opposite the steam table revealed the following: Mushroom and green onion open not sealed, cheese sauce and apple sauce in plain plastic bag not labeled or dated. Can green peas, mashed potatoes and barbeque sauce, tomato paste, and peaches were not labeled and dated. Cornbread and garlic bread in plain plastic bags were not labeled and dated. In an interview with the Cooperate Dietitian on 4/24/2023 at 3:45pm regarding the issues in the kitchen. She said that she was going to ensure that foods were sealed, dated, and labeled by in servicing the staff on labeling and dating of food items in the dry storage room, cooler and freezer. She also said she will have to do some cleaning. In an interview with the Dietary Manager on 4/24/2023 at 4:00pm she said that she expected the staff to labeled, sealed, and dated all food items. She said she had in-serviced the staff on cleaning of the kitchen floor and the equipment. She said that she was going to ensure that the kitchen was cleaned by Wednesday. In an interview with the RVP on 4/24/2023 at 4:15pm she said she was going to ensure the kitchen was cleaned starting 4/24/23. She said that she was checking the kitchen and when she was not available the HR person would sit in for her. She said she was going to talk with the Dietitian so they can come up with a plan to maintain compliance in the kitchen. In an interview with the Dietary Manager on 4/25/2023 at 4:15pm she said it was the expectation of the staff to label, seal, and date all food items when they are opened. She said they are expected to clean the equipment and clean the floor after each meal. She said they will have daily reminder until it becomes a normal routine, and not be reminded of what to do. Record review of the Nutrition Policies and Procedures dated 8/1/2020: Subject: safe Food Handling: Policy: Food acquisition, and distribution will comply with accepted food handling practices. Proper food handling is essential in preventing foodborne illness. Procedures: 4. Handle food carefully to avoid contamination with potential harmful debris, such as broken glass or glass chips, sweeping and the like. 5. Dishes, flatware, and glassware are free from chips, cracks, or stain. Food/Beverages Prepared and Served by Facility Staff for Patients or residents. 4. All foods are stored, prepared, and served at temperatures that prevent bacterial growth. Hot foods are maintained at 135 degrees F or higher and cold foods are maintained at 40 or below at point of service. At point of delivery hot foods should be 120 F, cold foods 41-45 degrees F or per state regulations. 6. Food is served with clean, sanitized utensils. There is no bare hand contact. 7. The food preparation area and utensils used to prepare food are cleaned and sanitized prior to each use, using approved washing and sanitizing techniques. Subject: Sanitation & Food Safety in food and nutrition Services The Nutrition Services Director (NSD) will assume responsibility for food safety and sanitation of the Nutrition Culinary Department 4.The Sanitation Review is completed monthly by the Dietitian and copied to the Administrator. The NSD completes the form at least weekly. 6. The Audit and the action plan are submitted to the administrator and the facility quality improvement coordinator/infection control coordinator. Record review of the sanitation report dated 3/28/2023 revealed a score of 0 (which means it is not up to standard) for the following items: All items covered, labeled, dated. Walls, floors, ceilings, vents, and doors clean. Daily cleaning schedule completed and followed. Can opener clean. Microwave clean. No cross contamination between clean and dirty side. All items air dried. Walls, racks, floors, clean. All carts and racks clean and in good repair. All painted surfaces clean with no chip. Emergency food and supplies available per facility policy and procedure. Comments: Missing shelving from coolers/freezers, order new can opener blade, replace cutting boards, post new cleaning schedule, paint all services with chipped paint, clean and paint ceiling vents. Steam table with food debris inside wells, steam table wells need repair. Dish machine logs, cooler/freezer logs not completed. Record review of facilities sanitation policy revealed that equipment and utensils will be sanitized after each use. A three-compartment sink is to be used for manual, washing, rinsing, and sanitizing utensils and equipment. If chemical sanitization is used it is recommended that the facility, follow the manufactures instructions. The Administrator was notified on 4/12/2023 at 10:30AM an Immediate Jeopardy (IJ) situation was identified due to the above failures. The template was provided at this time. The Plan of Removal was submitted by the facility and was accepted on 4/15 /2023 at 2:20pm and included: Plan of Removal F812 IJ Ecolab was contacted 4/11/23 to inspect the dish machine. Ecolab was onsite 4/12/23 and confirmed the dish machine is working properly and tested. The dishes were washed and sanitized using dishwashing liquid and / or sanitizer on 4/12/23 Food in the refrigerators, freezers and dry pantry was discarded that was spoiled, undated and unlabeled and on the floor by 4/12/23 The floor was cleaned to remove the debris. The three compartment is no longer full of dirty dishes. The steam table was cleaned to remove the burnt food particles in the wells. The sneeze guard was cleaned to remove dried food particles. The grill was cleaned to remove dried food particles and the stove was cleaned to remove burnt food particles. This will be completed by 4/13/23. The Dietary Departmental Leadership Policy, Sanitation and Food Safety in Food and Nutrition Services, Food service In a Disaster Policy, Food Preferences Diet History Policy, Meal Service for New Patients or Residents, Food Preparation, Menus Policies were reviewed by the Interim Certified Dietary Manager, Administrator, and New Certified Dietary Manager on 4/12; 4/13; 4/14. No revisions were needed. Ecolab onsite 4/12/23 to confirm dish machine was set up with chemicals. The Interim Certified Dietary Manager was re-educated by the National Director of Nutrition Services as the trainer on 4/12/23. The Interim Dietary Manager began working at the facility on 4/10/23 and was onsite 4/10; 4/11; 4/12. New Certified Dietary Manager started 4/13/23. Proper sanitation and food handling practices to prevent the outbreak of foodborne illness. Safe food handling for the prevention of foodborne illnesses begins when food is received from the vendor and continues throughout the facility's food handling processes Labeling, dating, and monitoring refrigerated or frozen food and pantry food items, including, but not limited to leftovers, so it is used by its use-by date, or frozen or discarded Temperatures are critical in preventing foodborne illness. Cooking food to the temperature and for the time specified below will either kill dangerous organisms or inactivate them sufficiently so that there is little risk to the resident if the food is eaten promptly after cooking. Low Temperature Dishwasher (chemical sanitization): o Wash -120 degrees - 140 degrees F; and o Final Rinse -50 ppm (parts per million) hypochlorite (chlorine) The dietary staff will be re-educated on the following by the Interim Certified Dietary Manager on 4/12/23 (date): Proper sanitation and food handling practices to prevent the outbreak of foodborne illness. Safe food handling for the prevention of foodborne illnesses begins when food is received from the vendor and continues throughout the facility's food handling processes Labeling, dating, and monitoring refrigerated or frozen food and food in pantry, including, but not limited to leftovers, so it is used by its use-by date, or frozen or discarded Temperatures are critical in preventing foodborne illness. Cooking food to the temperature and for the time specified below will either kill dangerous organisms or inactivate them sufficiently so that there is little risk to the resident if the food is eaten promptly after cooking. Low Temperature Dishwasher (chemical sanitization): o Wash -120 degrees - 140 degrees F; and o Final Rinse and checking of chlorine strips - 50 ppm with each cycle Cleaning schedules for the kitchen we established. Dietary competencies using the skills check protocol from the Food and Nutrition Services Policy Manual will be completed on the dietary staff by the Interim Certified Dietary Manager beginning on 4/12/2023 and completed by 4/13/23. This education and competencies will be completed by 4/13/23. Any member of dietary staff not receiving this information by this date will receive prior to next scheduled shift The Interim Certified Dietary Manager/designee will make rounds in the kitchen 3 times daily for 5 days to validate kitchen sanitation and food storage using the Sanitation Rounds tool and validate proper dishwashing technique and appropriate food temperatures, the 3 X weekly for 4 weeks then weekly thereafter starting 4/14/23 New Certified Dietary Manager will receive training regarding cleaning schedules, Emergency supplies/food, and sanitation on 4/14/23 by Interim Certified Dietary Manager. The Regional [NAME] President of Operations will oversee compliance of this plan. Regional VP/designee will complete sanitation inspection of the kitchen weekly effective 4/14/23. The Medical Director was notified of the Immediate Jeopardy and the contents of the plan of removal on 4/13/2023. An Ad Hoc (when necessary or needed) Quality Assurance Performance Improvement meeting was held on 4/13/2023 to review contents of this plan. Surveyor Verification of Plan of Removal was as follows: Record review of in-service records dated 4/11/2023 -4/19/2023 revealed that the Dietary Manager, Cooks and Dietary Aides were in-serviced on proper storage of leftovers, emergency supplies, food safety, food temperature, dish machine, sealed, labeling, and dating of food and appropriate liquids for pureed diet. Observation on 4/12/2023 at 5:00pm of the dish machine located in the kitchen revealed, the dish machine was working and the litmus paper changed color indicating that the sanitizer was present. Observation on 4/21/2023 at 11:00am of the Kitchen revealed food iwas dated, labeled, sealed and stored appropriately. Kitchen Observed clean. In an interview with [NAME] D on 4/21/2023 at 11:00am she stated he was in-serviced on kitchen sanitization, food temperature, storage of left over and dating and labeling of foods. The staff was able to demonstrate understanding of training. Interview conducted with [NAME] C on 4/21/2023 at 1:45pm, revealed he was in-serviced on sanitizing of dishes, pots and pans, food storage, food temperature, dating and labeling of foods. The staff was able to demonstrate understanding of the training. In an interview with [NAME] D on 4/24/2023 at 2:00pm he stated he was in-serviced on kitchen sanitization, food temperature, storage of left over and dating and labeling of foods. The staff was able to demonstrate understanding of training. In an interview with Dietary Aide G on 4/24/2023 at 1:55pm she stated she was in-serviced on kitchen sanitization, the dish machine, food temperature, storage of left over and dating and labeling of foods. The staff was able to demonstrate understanding of training. In an interview on 4/24/2023 at 4:30pm with the RVP she said they were doing kitchen checks had three time a day for five days and then two time and then once a day until the facility complies and all staff are trained. She said they will be doing weekly and random audits to ensure continued compliance. In an interview with the Dietitian on 4/25/2023 at 3:45PM she said that she was going to ensure that foods were dated and labeled. She said she will have to in-service the staff on labeling and dating of food items in the cooler and freezer. She also said she will have to do some cleaning. In an interview with the Dietary Manager on 4/25/2023 at 4:00pm she said that expectation of the staff was to label, sealed and dated all food items. She said had in-serviced the staff on cleaning of the kitchen floor and the equipment. She said that she was going to ensure that the kitchen was kept clean all the time and will always be complying. The RVP was notified that the IJ was lowered on 4/25/2023 at 5:26pm. However, the facility remained out of compliance at a severity of level of actual harm that is not immediate jeopardy and a scope of pattern due to the facility needing more time to monitor the plan of correction's effectiveness.

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

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