Kyakameena Care Center

Based on observation, interview and record review, the facility failed to ensure one of one sampled resident (Resident 1) received a written notification about the room change when Resident 1 was moved to another room.This failure resulted in violation of Resident 1's rights to receive written notice of the room change, including the reason for the change, before the resident's room in the facility was changed.During a review of Resident 1's admission Record, dated 12/17/25, the admission Record indicated Resident 1 was admitted in the facility on 10/10/25.During a review of Resident 1's Minimum Data Set (MDS, an assessment used to guide plan of care) dated 10/16/25, the MDS indicated Resident 1's Brief Interview of Mental Status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information) score was 15 out of 15, indicating intact cognitive status.During a telephone interview on 12/17/25 at 10:43 a.m. with Resident 1, Resident 1 stated, she was told by the wound care nurse on her last night in the facility that she will be moving to another room. Resident 1 stated there was no paperwork given to her to notify that she's moving to another room.During a concurrent interview and record review on 12/17/25 at 11:48 a.m. with Registered Nurse (RN) 1, Resident 1's Behavior Note, dated 12/4/25 at 8:33 a.m. was reviewed. The Behavior Note indicated, RN 1 communicated and explained the situation with Resident 1 regarding moving to another room. RN 1 stated she verbally informed Resident 1 of moving to another room. RN 1 stated that she did not provide a written notification to Resident 1.During a concurrent interview and record review on 12/17/25 at 11:59 a.m. with the Staffing Coordinator (SC), the facility Census List (a report showing all admitted patients, dated 12/4/25 at 11:03 a.m. was reviewed. The Census List indicated that an action code RC (room change) was associated with Resident 1. The SC stated Resident 1did have a room change from one room to another.During a concurrent interview and record review on 12/17/25 at 12:10 p.m. with the Director of Nursing (DON), the DON stated, she remembers verbally discussing the room change with Resident 1. The DON stated she was not aware of the room change policy, and that she did not provide a written notification Resident 1.During a concurrent interview and record review on 12/17/25 at 1:35 p.m. with RN 1,. RN 1 she could not locate any documentation indicating, a written notice of room change was entered or uploaded in Resident 1's Electronic Health Record.During a concurrent interview and record review on 12/17/25 at 1:37 p.m. with RN 1, the facility's policy and procedure (P&P) titled, Room Change/Roommate Assignment, dated 3/21 was reviewed. The P&P indicated, .4. Prior to changing a room or roommate assignment all parties involved in the change/assignment (e.g., resident and their representatives) are given. advance written notice of such change. RN 1 stated she was not aware of the room change policy.

Based on interview and record review, for four (Resident 1,10,19, and 27) of five sampled residents, the facility failed to electronically transmit accurate and complete Minimum Data Set (MDS -a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan), data to the CMS system within 14 days after completion of resident's assessment.Definition: CMS - The Centers for Medicare & Medicaid Services provides health coverage through Medicare and Medicaid-a government national health insurance program that provided health insurance for adults and children with limited income and resources.These failures had the potential to result in the delay of assessment of residents' needs, goals of care and inability to monitor each resident's progress over time. During a review of the MDS 3.0 Final Validation Report (FVR), dated 11/11/25, the FVR indicated Resident 1's quarterly assessment was completed on 10/14/25 and transmitted on 11/11/25.Review of MDS 3.0 FVR indicated Resident 10's quarterly assessments was completed on 9/19/25 and transmitted on 11/16/25.Review of MDS 3.0 FVR indicated Resident 19's quarterly assessment was completed on 10/12/25 and transmitted on 11/18/25.Review of MDS 3.0 FVP indicated Resident 27's quarterly assessment was completed on 10/13/25 and transmitted on 11/18/25.During an interview on 11/21/25 at 11:07 a.m. with MDS coordinator (MDSC), MDSC stated she was aware of the late completion of residents quarterly MDSs. MDSC stated she was recently hired and had been trying to catch up with the late MDSs.During an interview on 11/21/25 at 11:11a.m. with Administrator (Admin), Admin stated facility was aware of late completion of residents MDSs. Admin stated she newly hired staff to assist with the completion of residents MDSs.Review of the Long -Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.17., dated October 2019, indicated the Assessment transmission: quarterly assessments must be transmitted electronically withing 14 days of the MDS completion date plus 14 days. {Reference: https://downloads.cms.gov/files}

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility had six resident rooms (room [ROOM NUMBER], 25, 27, 29, 31 and 33) with multiple beds that provided less than 80 square feet 9sq ft) per resident who occupied these rooms.This failure had the potential to result in inadequate space for the delivery of care to each of the residents in each room or for storage of the residents' belongings. During an observation on 11/20/25 at 11:11 a.m. the following rooms had corresponding square footage (sq. ft.0 per bed were identified: Room Activity Room Size Floor Area23 Rt room [ROOM NUMBER].3 sq. ft 78.42 sq. ft/bed25 Rt room [ROOM NUMBER].3 sq. ft 78.42 sq. ft/bed27 Rt room [ROOM NUMBER].6 sq. ft 77.59 sq. ft/bed29 Rt room [ROOM NUMBER].6 sq. ft 77.59 sq. ft/bed31 Rt room [ROOM NUMBER].6 sq. ft 77.59 sq. ft/bed33 Rt room [ROOM NUMBER].6 sq. ft 77.59 sq. ft/bed During an interview on 11/20/25 at 11:14 a.m. with Resident 24, Resident 24 stayed in a room that accommodated more than four residents. Resident 24 stated that he had enough space for storage of his belonging and was comfortable had no complaints regarding bed space. During an interview on 11/20/25 at 11:49 a.m. with Certified Nursing Assistant (CNA 1), CNA 1 stated it was manageable to care for residents in rooms with more than four residents. CNA 1 stated it was easy to use shower chair and lifts in these rooms with no problem. During random observation of care and services from 11/18/25 through 11/21/25, there was sufficient space for the provision of care for the residents in all rooms. There was no heavy equipment kept in the rooms that might interfere with residents' care and each resident had adequate personal space and privacy. There were no complaints from residents regarding insufficient space for their belongings. There were no negative outcomes attributed to the decreased space and/ or safety concerns in the six rooms. Granting of room waiver recommended.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and record review, the facility had six resident rooms (room [ROOM NUMBER], 27, 29, 31, 33, and 35) that accommodated more than four residents in each room.This failure had the potential to result in inadequate space for the delivery of care to each of the residents in each room, or for storage of the residents' belongings.Findings: Room Number Number of Bedsroom [ROOM NUMBER] 5 bedsroom [ROOM NUMBER] 6 bedsroom [ROOM NUMBER] 6 bedsroom [ROOM NUMBER] 6 bedsroom [ROOM NUMBER] 6 bedsroom [ROOM NUMBER] 5 beds During an interview on 11/20/25 at 11:14 a.m. with Resident 24, Resident 24 stayed in a room that accommodated more than four residents. Resident 24 stated that he had enough space for storage of his belonging and was comfortable had no complaints regarding bed space. During random observation of care and services from 11/18/25 through 11/21/25, there was sufficient space for the provision of care for the residents in all rooms. There was no heavy equipment kept in the rooms that might interfere with residents' care and each resident had adequate personal space and privacy. There were no complaints from residents regarding insufficient space for their belongings. There were no negative outcomes attributed to the decreased space and/ or safety concerns in the six rooms. Recommend granting waiver of number residents per room.

Based on interview and record review, the facility failed to implement its Legionella Water Management Program policy and procedures when facilitydid not have a water management program. This failure had the potential risk for Legionnaires' disease, and unsafe water usage. During an interview on 11/21/25 at 8:55 a.m. with Administrator (Admin), Admin stated facility did not have a program for managing water systems to prevent Legionnaires' disease and had not tested water for legionella. During a review of the facility's policy and procedure (P&P) titled, Legionella Water Management Program, revised September 2022, the P&P indicated, Our facility is committed to the prevention, detection and control of water-borne contaminants, including Legionella.

Based on observation, interview and record review, the facility failed to complete a performance review for three out of three certified nursing assistants (CNA 2, 3, 4) at least once every 12 months.This failure had the potential for a lack of training for any potential deficiencies identified during the performance review process. During a review of personnel files, indicated CNA 2, 3, 4, hired 3/25, 2/22, 11/24 respectively, had no performance review for year 2025.During a concurrent interview and record review on 11/20/25 at 9:02 a.m. with the Director of Staff Development (DSD), CNA 2, 3, 4's CNA annual skills checklist dated 9/11/25, 10/16/25 and 11/4/25 respectively was reviewed, the DSD stated CNA 2, 3, 4 only had annual skills check list. The DSD stated there was no other form the facility had provided for the performance review. The DSD stated the CNA annual skills checklist was their performance review.During a follow up interview on 11/20/25 at 9:38 a.m. with the DSD, the DSD stated asking the facility Administrator (Admin), previous acting DSD and facility consultant for a copy of the performance review form when she first started as a DSD but was not provided. The DSD stated performance review should be completed from the date of hire and annually thereafter. The DSD stated the performance review would show how the CNA performs patient care. The DSD stated the performance review would help the CNA on what skills to improve on.During a concurrent observation and interview on 11/21/25 at 9:32 a.m. with the DSD, in front of nursing station 1, the DSD showed a form titled Employee Performance Review. The DSD stated the form will be used to complete the performance review.During a review of the facility's policy and procedure titled, Performance Evaluation, dated 6/10, indicated, 1. A performance evaluation will be completed on each employee at the conclusion of his/her 90-day probationary period, and at least annually thereafter.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, for three of three sampled residents (Resident 9, 19, and 55) the facility failed to have a formal written agreement with dialysis provider for residents needing dialysis (a treatment for kidney failure to remove waste products and excess fluids by external filtration of blood), that outline responsibilities for care coordination, communication, and emergency preparedness. This failure had the potential for Residents 9, 19 and 55 to not receive consistent care that meets professional standards.
During a review of Resident 19's admission Record (AR) dated 11/21/25, the AR indicated Resident 19 was admitted on [DATE] with principal diagnosis of end stage renal disease (ESRD- is the final stage of kidney failure, where the kidneys are no longer able to function adequately to keep the body healthy).
During a review of Resident 19's Order Summary Report (OSR) dated 4/20/23, OSR indicated, physician prescribed Resident 19 to receive hemodialysis every Monday, Wednesday and Friday at a dialysis provider.
During a review of Resident 55's admission Record (AR), the AR indicated on 12/13/24 Resident 55 was diagnosed with end stage renal disease (ESRD).
During a review of Resident 55's Order Summary Report (OSR) dated 5/13/25, OSR indicated, physician prescribed Resident 55 to receive hemodialysis every Monday, Wednesday and Friday at a dialysis provider.
During an interview on 11/20/25 at 10:28 a.m. with Administrator (Admin), Admin stated facility did not have a written agreement between the nursing home and the dialysis provider that details responsibilities for care and communication and emergency.
During an interview on 11/21/25 at 8:50 a.m. During an interview with Admin, Admin stated she had tried to reach out to dialysis provider but had not been able to contact the dialysis management.
2. During a review of Resident 9's admission Record, printed on 11/21/25, the admission Record indicated Resident 9 was admitted in the facility on 10/28/25 with a diagnosis of ESRD.
During a review of Resident 9's Order Summary Report, dated 10/28/25, the Order Summary Report indicated Resident 9 had an order to receive dialysis every Monday, Wednesday and Friday at a dialysis provider for ESRD.
During a review of Resident 9's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan), the MDS dated [DATE] indicated Resident 9 had dialysis treatments while a resident in the facility.
During an interview on 11/21/25 at 8:43 a.m. with the Admin, the Admin stated having difficulty getting contract from administrators of the dialysis center after trying to reach out.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 29) received adequate supervision to prevent accident hazards when: Resident 29 eloped from the facility and was found by the police in another town. Resident 29's incidents of elopements were not reported to the state department as required by federal or state regulations. Elopement is a situation in which a resident leaves the premises or a safe area without the facility's knowledge and supervision.This failure caused Resident 29 to continue to elope and had the potential to result in heat or cold exposure, dehydration or struck by motor vehicle. During a review of Resident 29's admission Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan), dated 2/4/25, the MDS indicated Resident 29's Basic Interview of Mental status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.) score was 10 and indicated mild cognitive impairment. The MDS indicated Resident 29 was not able to recall the correct year, month, and day of the week. MDS indicated Resident 29 had clear speech, difficulty communicating some words or finish thoughts but able if prompted or given time. MDS indicated Resident 29 had episode of wandering. MDS indicated Resident 29 needed supervision with walking helper provides verbal cues and contact guard assistance. MDS indicated Resident 29 had diagnoses that included unsteadiness on feet, cognitive communication deficit and aphasia (a brain disorder that affects how you speak and understand language). During a concurrent observation and interview on 11/18/25 at 10:53 a.m. with Resident 29, Resident 29 wandered up and down facility hallway. Resident 29 stated he left the facility because he wanted to see his family. Resident 29 stated he removed the wander guard on his ankle and placed under his pillow before he left. Resident 29 stated that the feeling of wander guard attached to his ankle messed with his head. Resident 29 said he did not like wander guard because wander guard made him felt as if he was in jail. During a review of Resident 29's admission Record (AR), AR indicated Resident 29 was admitted to the facility on [DATE]. During a review of Resident 29's Wandering/Elopement Assessment (EA) dated 3/3/25, indicated, Resident 29 eloped from the facility on 3/3/25 at 6:50 a.m. EA indicated Certified Nursing Assistant (CNA) found Resident 29 at the bus station. Resident 29 was brought back to the facility. During a review of Resident 29's Progress Notes (PN) dated 5/28/25, PN indicated Resident 29 eloped at 9:10 p.m. from the facility. Staff notified police. Police found Resident 29 at downtown, informed facility at 10:25 p.m. and returned Resident 29 to the facility. During a review of Resident 29's PN dated 11/5/25, PN indicated Resident 29 eloped from the facility and police department was notified. During a review of Resident 29's EA dated 11/7/25, EA indicated, Resident 29 was found wandering in another town. Resident 29 was evaluated at the emergency department and returned back to the facility via ambulance. During a review of Resident 29's care plan dated 11/10/25, care plan indicated Resident 29 leaves facility without notifying staff. Interventions included that staff would monitor Resident 29's location every shift. During an interview on 11/19/25 at 7:59 a.m. with Administrator (Admin), Admin stated Resident 29 had eloped from the facility on more than one occasion. Admin stated Resident 29 eloped from the facility on 11/5/25 was found in another town by the police and returned to the facility. Admin stated facility had not reported the prior incidents of elopements to the state department. Admin stated facility tried to report the recent elopement of 11/5/25 but find out later that the fax report did not went through. During a concurrent interview and record review on 11/19/25 at 9:31 a.m. with Director of Nursing (DON), Resident 29's admission MDS assessment dated [DATE], EA s and progress notes were reviewed. DON stated Resident 29 had eloped on more than one occasion. DON stated she was not aware that Resident 29's risk for elopement was not addressed with care plan because DON was hired after Resident 29's admission to the facility. DON stated facility intervention included monitoring location and wander guard. DON stated Resident 29 continued to elope because Resident 29 removed his wander guard. DON stated Interdisciplinary team (IDT-an interdisciplinary team is a group of professionals from different fields who collaborate to address complex residents' need) had not met to review Resident 29's repeated episode of elopement. DON could not provide comprehensive care plan that addressed Resident 29's risk for wandering and elopement, repeated incidents of Resident 29's elopements with appropriate interventions with each incident of elopement.During a review of the facility's policy and procedure (P&P) titled, Unusual Occurrences Reporting, dated 2001, the P&P indicated, As required by federal or state regulations, our facility reports unusual occurrences or other reportable events which affect the health, safety, or welfare of our residents, employees or visitors. Unusual occurrences shall be reported via telephone to appropriate agencies as required by current law and/or regulations within twenty-four (24) hours of such incident or as otherwise required by federal and state regulations.During a review of the facility's policy and procedure (P&P) titled, Wandering and Elopements, dated 2001, the P&P indicated, The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure two of two sampled residents (Resident 30 and 48) were provide toenails care and treatment, in accordance with professional standards of practice, when: 1. For Resident 30, facility did not provide appropriate toenails care and treatment for thick, long, brownish black toenails.2. For Resident 48, facility did not provide toenail fungal treatment and toenail trimming for 15 months.This failure resulted in Resident 30 and 48's overgrowth of toenails and increased risk for injury and infection.1.During a review of Resident 30's admission Minimum Data Set (MDS, a federally mandated resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan), dated 4/23/25, the MDS indicated Resident 30's Basic Interview of Mental status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.) Resident 30's score was 09 meaning impaired cognition. MDS indicated Resident 30 was admitted to the facility on [DATE]. Resident 30 had clear speech, able to make self-understood and understood others. MDS indicated Resident 30's diagnoses included Diabetes Mellitus (DM - a chronic disease where the body doesn't make enough insulin causing high level of sugar in blood).
During a concurrent observation and interview on 11/18/25 at 10:06 a.m. Resident 30 laid in bed, awake and verbally responsive. Resident 30 had long, thick brownish black toenails. Resident 30 stated he had requested staff to help with his toenail care and is waiting for their assistance.
During a concurrent observation and interview on 11/18/25 at 10:13 a.m. with Assistant Director of Nursing (ADON), Resident 30 toenails was long, thick, brownish black coloration. ADON stated Resident 30 needed referral to podiatry. ADON stated facility process was for Certified Nursing Assistant (CNA) to report overgrown toenails and notified charge nurse who refers to podiatrist.
During an interview on 11/18/2025 at 1:17 p.m. with Social Services Director (SSD), SSD stated Resident 30 was not seen by the podiatrist due to Resident 30's insurance. SSD stated the podiatrist only accept Medicare part B.
2.During a review of Resident 48's admission Record (AR) dated 11/20/25, the AR indicated Resident 48 was admitted to the facility in July 2024 with multiple diagnoses, including diffuse traumatic brain injury (a serious head injury that damages many parts of the brain), seizures (a sudden uncontrollable shaking with rapid and rhythmic body movement), difficulty in walking and lack of coordination.
During a review of Resident 48's Minimum Data Set (MDS, a resident assessment tool to guide resident care) dated 7/31/25, the MDS indicated Resident 48 had a Brief Interview for Mental status (BIMS, a scoring system used to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information) score of 13, indicating Resident 48 was cognitively intact.
During an observation and interview on 11/20/25 9:25 a.m., Resident 48 was observed lying in bed with long toenails on right 1st, 2nd and 3rd toes, and on the left 1st, 2nd, 3rd and 4th toes. Resident 48's two big toenails were thick, long, discolored yellow and brown and protruding, right 2nd, 3rd, left 2nd, 3rd and 4th toenails were long and curved downward, and left 2nd and 4th toenails were loose. Resident 48 stated she could flip the two loose toenails backward and was afraid they could be accidentally ripped off. Resident 48 stated she has not been seen by a podiatrist since her admission to the facility.
During an interview on 11/20/25 at 9:51 a.m., CNA 5 stated that she had reported to nurses and administrator that Resident 48's toenails need to be trimmed. CNA 5 stated it was difficult to assist the resident with putting on socks due to the long and loose toenails.
During an interview on 11/20/25 at 8:45 a.m., Social Services Director (SSD) stated due to insurance reasons, Resident 48 has not been seen by the podiatrist. SSD stated she was not sure when Resident 48's toenails were last trimmed by a podiatrist. SSD stated residents should be seen by a podiatrist every 6 months and the team were working to ensure that Resident 48 would be seen by a podiatrist.
During a record review of Resident 48's Order Summary Report (OSR) dated 11/20/25, the OSR indicated orders for podiatry care every 61 days as needed for mycotic (fungal-infected) nails, date 7/23/24, and a podiatry referral for fungal nail dated 10/22/25.
During a review of the facility's policy and procedure (P&P) titled, Foot Care, dated October 2022, the P&P indicated, Residents with foot disorders or medical conditions associated with foot complications are referred to qualified professionals. Foot disorders that require treatment include corns, neuromas, calluses, hallux valgus, hammertoe, heel spurs, and nail disorder.

Based on interview and record review, the facility failed to ensure one of one sampled resident (Resident 49) was assisted to receive proper vision treatment to maintain vision when Resident 49 was not assisted with referral for cataract surgery as ordered by the doctor.This failure had the potential to cause Resident 49 decline in vision, blindness and emotional distress. During a review of Resident 49's Minimum Data Set (MDS- a federally mandated resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan), dated 8/21/25, the MDS indicated Resident 49's Basic Interview of Mental status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status). Resident 49's score was 13 meaning intact cognition. Resident 49 had clear speech, able to make self-understood and understood others. MDS indicated Resident 49's diagnoses included anxiety disorder (a group of mental health conditions characterized by persistent and excessive feelings of worry, fear or panic that impair daily life), and Depression (a serious mood disorder characterized by persistent feelings of sadness or loss of interest which negatively impact daily life).During an interview on 11/20/25 at 8:36 a.m. with Resident 49, Resident 49 stated that he had problem with his vision. Resident 49 stated he was not able to read or use his lap top computer. Resident 49 said eye doctor came to see him at the facility last year. Resident 49 stated the eye doctor diagnosed that Resident 49 had Cataract in the right eye and gave referral for ophthalmology consult and facility to schedule appointment. Resident 49 stated the referral was presented to the staff. Resident 49 stated he had not seen ophthalmologist and was frustrated and don't know what to do. During a review of Resident 49's medical record, titled, Advanced Eyecare dated 3/29/24, the eye care record indicated, Resident 49 was seen by eye doctor and diagnosed with cataract right eye with referral to ophthalmology - facility to schedule appointment. During a review of Resident 49's Order Summary Report (OSR), dated 7/3/24, the OSR indicated physician ordered that facility may refer Resident 49 to ophthalmology for cataract surgery. During an interview on 11/20/25 at 8:13 a.m. with Social Services Director (SSD), SSD stated usually eye doctor visit facility every six months. SSD stated that Resident 49's insurance did not cover vision and was not seen by the eye doctor.During a review of the facility's policy and procedure (P&P) titled, Visually Impaired Resident, Care of, dated 2001, the P&P indicated, It is our responsibility to assist the resident and representatives in locating available resources (e.g., Medicare, Medicaid or local organizations), scheduling appointments and arranging transportation.

Based on interview, and record review the facility failed to ensure one of three sampled residents (Resident 49) was provided appropriate treatment and services to maintain or improve functional mobility to carry out the activities of daily living, when: For Resident 49 facility did not provide Restorative Nursing Services (RNA) treatment for decline in functional mobility as ordered by the physician. RNA is restorative nursing care consisting of nursing interventions to help promote optimal safety and independence. During a review of Resident 49's Minimum Data Set (MDS- a federally mandated resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan), dated 8/21/25, the MDS indicated Resident 49's Basic Interview of Mental status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status). Resident 49's score was 13 meaning intact cognition. Resident 49 had clear speech, able to make self-understood and understood others. MDS indicated Resident 49's diagnoses included anxiety disorder (a group of mental health conditions characterized by persistent and excessive feelings of worry, fear or panic that impair daily life), and Depression (a serious mood disorder characterized by persistent feelings of sadness or loss of interest which negatively impact daily life).During an interview on 11/20/25 at 8:36 a.m. with Resident 49, Resident 49 stated he needed regular exercise to help with his mobility. Resident 49 request regular exercise to walk outside of the facility twice a day as ordered by his physician. Resident 49 stated he was walked sometimes once a day and most days nobody walks him. During a review of Resident 49's physician order dated 9/23/25, the physician order indicated, Resident 49 to receive RNA walk two times a day, three times weekly without a front wheel walker on Tuesday, Thursday, Sunday for 12 weeks.During a concurrent interview and record review on 11/20/25 at 9:02 a.m. with Restorative Nursing Assistant (RNA 1), Resident 49 physician order dated 9/23/25 was reviewed. RNA 1 stated Resident 49 was on RNA program. RNA 1 stated she was not aware of the order to walk Resident 49 twice daily. RNA 1 stated she walked Resident 49 once daily when RNA 1 was on duty. RNA 1 could not provide Resident 49's RNA treatment records from September 2025 to November 2025.During a review of Resident 49's at risk for decline in functional mobility, dated 9/29/25, care plan indicated Resident 49 is at risk for decline in functional mobility. Resident 49's care plan indicated interventions included, RNA two times a day, three times a week. Resident 49 to walk for 30 minutes twice a day outside. Maybe walk inside due to weather with supervision level without front wheel walker FWW).During a review of the facility's policy and procedure (P&P) titled, Restorative Nursing Services, dated July 2017, the P&P indicated, Residents will receive restorative nursing care as needed to help promote optimal safety and independence

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to complete and update the care plan in a timely manner to reflect residents' care needs for two of two investigated residents when:1. For Resident 48 facility did not update care plan to accurately reflect the resident's required transfer method. This failure resulted in Resident 48 being transferred incorrectly and sustained a left lower leg fracture.2. For Resident 29 facility did not develop comprehensive care plan within 7 days of completion of assessment to address risks of elopement and Interdisciplinary Team did not review Resident 29 episodes of elopement from the facility with appropriate interventions. IDT- Interdisciplinary Team means professional disciplines that work together to provide the greatest benefit to the resident which includes the resident, the resident's family and/or representative, whenever possible, develops and implements approaches to care that are both clinically appropriate and person-centered.This failure resulted in Resident 29 to continue to elope from facility and potential risk to result in heat or cold exposure, dehydration or struck by motor vehicle.
1.During a review of Resident 48's admission Record (AR) dated 11/20/25, the AR indicated Resident 48 was admitted to the facility in July 2024 with multiple diagnoses, including diffuse traumatic brain injury (a serious head injury that damages many parts of the brain), seizures (a sudden uncontrollable shaking with rapid and rhythmic body movement), difficulty in walking and lack of coordination.
During a review of Resident 48's History and Physical (H&P) dated 7/3/24, the H&P indicated Resident 48 had Myoclonic jerks (very quick, sudden muscle contraction).
During a review of Resident 48's Minimum Data Set (MDS, a resident assessment tool to guide resident care) dated 7/31/25, the MDS indicated Resident 48 had a Brief Interview for Mental Status (BIMS, a scoring system used to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information) score of 13, indicating Resident 48 was cognitively intact.
During a review of Resident 48's Documentation Survey Report (ADL float sheet) from 8/1/25 to 8/10/25, the ADL float sheet indicated Resident 48 was dependent (Helper does all the effort. Resident does none of the effort to complete the activity) for transferring from bed to chair or from chair to bed on 12 out of 16 occasions, substantial/maximal (Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than the effort.) assistance on 2 out of 16 occasions, partial/moderated (Helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort.) assistance on 1 out of 16 occasions, and set up (Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity.) assistance on 1 out of 16 occasions.
During an interview on 11/20 /25 9:25 a.m., Resident 48 stated staff had been using a standing lift to transfer her from wheelchair to bed or from bed to wheelchair for a long time due to her sudden trembling and jerking movements.
During an interview on 11/20/25 at 9:30 a.m., Resident 48 stated that on 8/11/25 at 10:30 a.m., while two CNAs transferring her from a wheelchair to bed without using a standing lift, her left leg was twisted and fractured. Resident 48 stated she was sent to the hospital on [DATE].
During an interview on 11/20/25 at 9:35 a.m., Resident 48 stated she became nervous during the transfer and began trembling. Resident 48 stated she heard a popping sound during the transfer and felt a burning sensation in her left lower leg afterward.
During a review of Resident 48's X-ray report dated 8/11/25, the X-ray report indicated: oblique fracture (the break is slanted) deformities (a body part does not look normal in shape) of the distal tibia (shine bone) and fibula (shin bone) shaft without displacement. Acute distal tibia and fibula fractures of the left lower leg.
A record review of Resident 48's after visit (Alta Bates Emergency) summary date 8/11/25, the visit summary indicated a closed fracture of distal end of left tibia, initial encounter.
During an interview on 11/20/25 at 9:48 a.m., Certified Nursing Assistance (CAN) 5 stated staff had been using a standing lift to transfer Resident 48 due to her involuntary movements. CNA 5 stated there was no place for CNAs to reference to determine the transfer method or equipment to use for Resident 48. CNA 5 stated that she knew the method because she was Resident 48's regular CNA, but on-call and registry staff did not know.
During a phone interview on 11/20/25 at 10:24 a.m., CNA 6 stated she was an on-call CNA. CNA 6 stated on 8/11/25, at 10:30 a.m., Resident 48's assigned CNA was to be giving another resident a shower, and she was asked to assist Resident 48 back to bed. CNA 6 stated she positioned Resident 48's wheelchair on the left side of the bed, facing the head of the bed, and placed her left foot between Resident 48's feet before standing the resident up.
During a phone interview on 11/20/25 at 10: 27 a.m., CNA 6 stated during the pivot transfer, Resident 48 began shaking. CNA 6 stated she sat Resident 48 on the edge of the bed but did not hear any popping sound. CNA 6 stated Resident 48 complaining of left ankle pain after being seated. CNA 6 stated at that time, Resident 48's assigned CNA entered the room, and CNA 6 left the resident with the assigned CNA and went out to report the incident to the charge nurse.
During a phone interview on 11/20/25 10:30 a.m., CNA 6 stated that she did not know a standing lift was required to transfer Resident 48, and she did not use a gait belt during the transfer. She stated she received an in-service on Safe Patient Transfer on 8/18/25, after the incident.
On 11/20/25 at 8:40, with Director of Staff Development (DSD), the facility's policy titled Safe Lifting and Movement of Residents, revision date July 2017 and in-service record titled Safe Patient Transfer dated 8/18/25 were reviewed. DSD stated residents' care plan should include the appropriate transfer method. DSD stated a gait belt should be used while transferring resident if mechanical lift is not used. DSD stated she provided an in-service to CNA 6 after the incident.
During an interview on 11/20/25 11:19 a.m., Licensed Vocational Nurse (LVN) 1 stated that CNA 6 transferred Resident 48 alone without using standing lift, which resulted in Resident 48's left lower leg fracture. LVN 1 stated the care plan should indicate that a standing lift is required for transferring Resident 48. LVN 1 stated the care plan should be updated regularly by the IDT and as needed by nurses.
On 11/21/25 at 9:20 a.m., with MDS Coordinator (MDSC), Resident 48's care plan of limited physical mobility dated 7/24/24, revision dated 8/29/24 was reviewed. MDSC stated the care plan should include the transfer method for Resident 48. MDSC stated the care plan should be reviewed and revised quarterly according to the MDS schedule and as needed.
On 11/21/25 at 9:23 a.m., with MDSC, during a concurrent interview and record review of Resident 48's care plan created on 8/11/25, the care plan indicated during transfer, Resident 48 hit her left lower leg on the side of the bed frame and heard a popping sound .Resident 48 has a short cast with splint in place.
During an interview on 11/21/25 at 9:53 a.m., Director of Nursing (DON) stated the care plan should be updated and that is the responsibility of all departments. When asked how on-call and registry staff were expected to be informed of residents' care needs, the DON stated that they received information through verbal reports during shift changes from nurse to nurse and CNA to CNA. When asked if the method for transferring residents should be included in the care plan and how often the care plan should be updated, DON stated, I don't have the answer.
During an interview on 11/21/25 at 11:30 am., Director of Rehab (DR) stated she was aware that staff had been using a lift to transfer Resident 48 due to the resident's severe trembling related to a massive brain injury. DR stated Resident 48 was not on the therapy case load; therefore, the therapy department did not update the care plan.
During a review facility's Policy and Procedure (P&P) titled Safe Lifting and Movement of Residents, revision date July 2017 indicated Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan.
During a review facility's P&P titled Care plans, Comprehensive Person-Centered revision date March 2022, the P&P indicated A comprehensive, person-centered care plan that includes measurable objective and timetable to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The interdisciplinary team reviews and updates the care plan: .d. at least quarterly, in conjunction with the required quarterly MDS assessment.
2.During a review of Resident 29's admission Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan), dated 2/4/25, the MDS indicated Resident 29's Basic Interview of Mental status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.) score was 10 and indicated mild cognitive impairment. The MDS indicated Resident 29 was not able to recall the correct year, month, and day of the week. MDS indicated Resident 29 had clear speech, difficulty communicating some words or finish thoughts but able if prompted or given time. MDS indicated Resident 29 had episode of wandering. MDS indicated Resident 29 needed supervision with walking helper provides verbal cues and contact guard assistance. MDS indicated Resident 29 had diagnoses that included unsteadiness on feet, cognitive communication deficit and aphasia (a brain disorder that affects how you speak and understand language).
During a concurrent observation and interview on 11/18/25 at 10:53 a.m. with Resident 29, Resident 29 wandered up and down facility hallway. Resident 29 stated he left the facility because he wanted to see his family. Resident 29 stated he removed the wander guard on his ankle and placed under his pillow before he left. Resident 29 stated that the feeling of wander guard attached to his ankle messed with his head. Resident 29 said he did not like wander guard because wander guard made him felt as if he was in jail.
During a review of Resident 29's admission Record (AR), AR indicated Resident 29 was admitted to the facility on [DATE].
During a review of Resident 29's Wandering/Elopement Assessment (EA) dated 3/4/25, indicated, Resident 29 was at risk for elopement. EA indicated Resident 29 eloped from the facility on 3/3/25 at 6:50 a.m. EA indicated Certified Nursing Assistant (CNA) found Resident 29 at the bus station. Resident 29 was brought back to the facility.
During a review of Resident 29's Progress Notes (PN) dated 5/28/25, PN indicated Resident 29 eloped at 9:10 p.m. from the facility. Staff notified police. Police found Resident 29 at downtown, informed facility at 10:25 p.m. and returned Resident 29 to the facility.
During a review of Resident 29's PN dated 11/5/25, PN indicated Resident 29 eloped from the facility and police department was notified.
During a review of Resident 29's EA dated 11/7/25, EA indicated, Resident 29 was found wandering in another town. Resident 29 was evaluated at the emergency department and returned back to the facility via ambulance.
During a review of Resident 29's care plan report initiated 11/10/25, indicated Resident 29 leaves facility without notifying staff with intervention that staff will monitor resident's location every shift and engage in activities.
During an interview on 11/19/25 at 7:59 a.m. with Administrator (Admin), Admin stated Resident 29 had eloped from the facility on more than one occasion. Admin stated Resident 29 eloped from the facility on 11/5/25 was found in another town by the police and returned to the facility. Admin stated facility had not reported the prior incidents of elopements to the state department. Admin stated facility tried to report the recent elopement of 11/5/25 but find out later that the fax report did not went through.
During a concurrent interview and record review on 11/19/25 at 9:31 a.m. with Director of Nursing (DON), Resident 29's admission MDS assessment dated [DATE], EA s and progress notes were reviewed. DON stated Resident 29 had eloped on more than one occasion. DON stated she was not aware that Resident 29's risk for elopement was not addressed with care plan because DON was hired after Resident 29's admission to the facility. DON stated facility intervention included monitoring location and wander guard. DON stated Resident 29 continued to elope because Resident 29 removed his wander guard. DON stated Interdisciplinary team (IDT-an interdisciplinary team is a group of professionals from different fields who collaborate to address complex residents' need) had not met to review Resident 29's repeated episode of elopement. DON could not provide comprehensive care plan that addressed Resident 29's risk for wandering and elopement, repeated incidents of Resident 29's elopements with appropriate interventions with each incident of elopement.
During a review of the facility's policy and procedure (P&P) titled, Wandering and Elopements, dated 2001, the P&P indicated, The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents.
During a review of facility's policy and procedure (P&P) titled, Care Plan, Comprehensive Person-Center, dated 2001, the P&P indicated, The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission. The IDT in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident).

Based on interview and record review the facility failed to ensure one (Resident 4) of seven sampled residents' rights was free from misappropriation of property and exploitation when Resident 4's missing pants and tops were not replaced or reimbursed. This failure had the potential to cause Resident 4 emotional distress. During a review of Resident 4's admission Minimum Data Set (MDS- a federally mandated resident assessment and care guide tool), dated 7/13/25, the MDS indicated Resident 4's Basic Interview of Mental status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.) Resident 4's score was 13 meaning intact cognition. Resident 4 had clear speech, able to make self-understood and understood others. MDS indicated Resident 4's diagnoses included Depression (a serious mood disorder characterized by persistent feelings of sadness or loss of interest which negatively impact daily life).During an interview on 11/20/25 at 11:57 a.m. with Resident 4, Resident 4 stated she reported missing five jeans' pants, three tops and underwear to the staff and Director of Nursing (DON) last month. Resident 4 stated her closet, and laundry were checked by staff and could not find her missing personal possession. Resident 4 stated DON was aware of her missing personal items. Resident 4 said DON asked Resident 4's daughter to replace her missing pants and tops and then facility will reimburse Resident 4's daughter. Resident 4 stated she did not want her daughter to take up the responsible of replacing missing items because Resident 4's daughter struggled financially. During a review of Resident 4's Inventory of Personal Possessions (IPP) dated 7/7/25, the IPP indicated one shirt, pants, socks, brassier and jacket were identified upon admission to the facility and entered into Resident 4's IPP record.During an interview on 11/20/25 at 12:04 p.m. with DON, DON stated she was aware of Resident 4's missing pants and tops. DON stated Resident 4's daughter was asked to replace the missing items and facility will reimburse. DON stated she was not aware Resident 4's daughter struggle financially.During an interview on 11/20/25 at 3:54 p.m. with Administrator (Admin), Admin stated she was aware of Resident 4 missing pants and tops. Admin stated Resident 4's daughter was asked to replace the missing pants and tops and facility will reimburse her.During a review of the facility's policy and procedure (P&P) titled, Investigating Incidents of Theft and/or Misappropriation of Resident Property, revised April 2017, the P&P indicated, Residents are not required or requested to waive facility liability for loss or misappropriation of personal property.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure two of two sampled residents (Resident 3 and Resident 4) Preadmission Screening and Resident Review (PASRR) were screened accurately and referred to the appropriate state mental authority for Level II PASRR evaluation and determination when Resident 3 and 4 with diagnosis of schizophrenia, bipolar and major depression were screened and documented as not having serious mental illness.(PASRR is a federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are appropriately placed in nursing homes for long term care).This failure had the potential to prevent residents from receiving appropriate required mental health services. During a review of Resident 3's Annual Minimum Data Set (MDS-an assessment screening tool used to guide care), dated 8/18/25 the MDS indicated Resident 3 was admitted to the facility on [DATE] with diagnosis that included schizophrenia (a severe mental health condition that causes a breakdown between a person's thoughts and reality) Bipolar disorder ( a mental health condition characterized by intense shifts in mood, energy, and activity levels, ranging from manic highs to depressive lows) and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities).During a concurrent interview and record review on 11/18/25 at 2:34 p.m. with Director of Nursing (DON) and Administrator (Admin) Resident 3's PASRR Level I screening dated 8/21/18 was reviewed. PASRR Level I indicated Resident 3 did not had a diagnosis of serious mental illness. DON stated Resident 3's PASRR Level I was not accurately screened or referred to the appropriate state mental authority for Level II PASRR evaluation and determination.During a review of Resident 4's admission Minimum Data Set (MDS-an assessment screening tool used to guide care), dated 7/13/25, the MDS indicated Resident 4 was admitted to the facility on [DATE] with diagnosis that included Major Depressive Disorder (a mental health condition characterized by persistent feelings of sadness and hopelessness). During a concurrent interview and record review on 11/18/25 at 2:34 p.m. with Director of Nursing (DON) and Administrator (Admin), Resident 4's PASRR Level I screen dated 7/5/25 was reviewed. PASRR Level I indicated Resident 4 did not have a diagnosis of serious mental illness. DON stated Resident 4's Level I PASRR was initiated from hospital before admission to facility. Admin stated facility's process was for the admission coordinator to review residents PASRR upon admission from the hospital and determine if there is required follow up. DON stated Resident 4's PASRR Level I was not accurately screened or referred to the appropriate state mental authority for Level II PASRR evaluation and determination.During a review of the facility's policy and procedure (P&P) titled, Preadmission Screening and Resident Review (PASRR), dated August 2025, the P&P indicated, The PASRR Level 1 screening is used to identify if an individual that is being admitted to a nursing facility has or is suspected of having a serious mental illness (SMI) or ID/DD/RC.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to accurately code three out of four sampled resident's (Resident 27, 31 and 49) Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan) when:1. For Resident 49 section B was not coded accurately for vision.2. Facility inaccurately coded No to No natural teeth or tooth fragments when Resident 27 has no natural teeth. This failure resulted in inaccurate reflection of Resident 27's oral/dental status and had the potential to affect Resident 27's nutrition, oral care, and dietary needs.3. Resident 31's hospice care item was incorrectly coded on MDS to reflect Resident 31's choice.These failures resulted in an inaccurate reflection of Resident 27 and 49's clinical condition which had the potential to affect their health care outcomes.
1.During a concurrent observation and interview on 11/20/25 at 8:36 a.m. with Resident 49, Resident 49 stated he had problem with seeing and using his computer. Resident 49 stated he was not able to read or use his laptop. Resident 49 said the eye doctor came to see him at the facility last year. Resident 49 stated eye doctor diagnosed that Resident 49 has Cataract and gave a referral to ophthalmology- facility to schedule appointment. Resident 49 stated the referral was presented to the staff. Resident 49 stated he had not seen the ophthalmologist and was frustrated and don't know what to do.
During a review of Resident 49's Annual Minimum Data Set (MDS), Resident Assessment and Care Screening tool used to guide care, dated 8/21/25 section B indicated Resident 49 had adequate vision sees fine detail such as regular print in newspapers/books.
During a concurrent interview and record review on 11/20/25 at 8:13 a.m. with MDS coordinator (MDSC), Resident 49 MDS section B - Hearing, Speech, and Vision dated 8/21/25 and Eyecare report dated 3/29/24 were reviewed. Eyecare report indicated Resident 49 had cataract. MDS section B indicated Resident 49 had adequate vision. MDSC stated that the MDS assessment section B was not coded accurately.
2.During a review of Resident 27's admission Record (AR) dated 11/20/25, the AR indicated Resident 27 was admitted to the facility in June 2018.
During an observation on 11/18/25 at 1:01p.m., Resident 27 was observed lying in bed with no nature teeth and no dentures in place.
On 11/20/25 at 1:43 p.m., during a concurrent interview and review of Resident 27's nursing admission screening/history dated 4/30/18, MDS Coordinator (MDSC) stated that the nursing admission screening/history indicated Resident 27 had no nature teeth.
On 11/20/25 at 1:54 p.m., during a record review and interview with the MDSC, the annual MDS assessment dated [DATE] was reviewed. MDSC stated the item for no nature teeth to tooth fragments should have been coded as yes. MDSC stated that MDSC should assess the resident and review the nursing assessment prior to completing the MDS to ensure accuracy.
3. During a review of Resident 31's AR dated 11/21/25, the AR indicated Resident 31 was admitted to the facility in April 2025.
During a review of Resident 31's Order Summary Report (OSR) dated 11/21/25, the OSR indicated an order for admission to Sutter Hospice on routine care with a terminal diagnosis of end stage renal disease (ESRD) dated 4/29/25.
On 11/20/25 at 1:57 p.m., during an interview and review of Resident 31's MDS admission assessment dated [DATE], MDSC stated that the hospice care item was incorrectly coded. MDSC explained that it was a coding error and did not reflect Resident 31's choice.

Based on interview and record review, for four (Resident 1,10, 19, and 27) of five sampled residents, the facility failed to ensure quarterly Minimum Data Set assessments (MDS - a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan) were completed not less frequently than once every three months according to the regulation. This failure had the potential to result in delayed assessment of residents' needs, goals of care and inability to monitor each residents' progress over time. During a review of resident 1,10, 19, and 27's MDS assessment records the following quarterly MDSs were not completed every three months:Resident 1' MDS assessment indicated the last quarterly MDS assessment was completed on 10/28/25 over 120 days.Resident 10's MDS assessment indicated the last quarterly assessment was completed on 10/3/25 over 120 days.Resident 19's MDS assessment indicated the last quarterly assessment was completed on 10/12/25 over 120 days. Resident 27's MDS assessment indicated the last quarterly assessment was completed on 11/2/25 over 120 days. During an interview on 11/21/25 at 11:07 a.m. with MDS coordinator (MDSC), MDSC stated she was aware of the late completion of residents quarterly MDSs. MDSC stated she was recently hired and had been trying to catch up with the late MDSs.During an interview on 11/21/25 at 11:11a.m. with Administrator (Admin), Admin stated facility was aware of late completion of residents MDSs. Admin stated she newly hired staff to assist with the completion of residents MDSs.During a review of the Long -Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.17.1, dated October 2019, indicated the quarterly assessment should be completed not later than 14 days after ARD (Assessment Reference Date). The Quarterly assessment is used to track a resident's status to ensure critical indicators of gradual change in a resident's status are monitored. The quarterly assessment is an OBRA (Omnibus Budget Reconciliation Act) non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous OBRA assessment of any type. {Reference: https://downloads.cms.gov/files}

Based on observation, record review, interview, and document review, the facility failed to ensure enhanced barrier precautions were implemented for 1 (Resident #26) of 14 sampled residents.
Findings included:
The Enhanced Standard Precautions for Skilled Nursing Facilities (SNF), 2019 published by the California Department of Public Health (CDPH), revealed, CDPH recommends the use of Enhanced Standard precautions, primarily the use of gowns and gloves for specific care activities, based on the resident's characteristics that are associated with a high risk of MDRO [multidrug-resistant organism] colonization and transmission: Table 1. Characteristics of Residents at High Risk for MDRO Colonization and Transmission Functional Disability: Totally dependent on others for assistance with activities of daily living Incontinence: Habitual soiling with stool or wetting with urine Presence of indwelling devices: urinary catheter, feeding tube, tracheostomy tube, vascular catheters Ventilator-dependence Wounds or presence of pressure ulcer (unhealed) Implement Enhanced Standard Precautions for high risk residents: * Place the high-risk resident in a single bed room. When a single bed room is not available, cohort the resident with a compatible roommate, such as a resident with the same MDRO or resistance mechanism when known. * Wear gowns and gloves while performing the following tasks associated with the greatest risk for MRDO contamination of HCP [health care personnel] hands, clothes and the environment: * Morning and evening care * Device care, for example, urinary catheter, feeding tube, tracheostomy, vascular catheter * Any care activity where close contact with the residents is expected to occur such as bathing, peri-care, assisting with toileting, changing incontinence briefs, respiratory care
An admission Record indicated the facility admitted Resident #26 on 09/08/2020. According to the admission Record, the resident had a medical history that included diagnoses of cutaneous abscess of buttock, cellulitis of buttock, functional quadriplegia, chronic osteomyelitis, and neuromuscular dysfunction of bladder.
A quarterly Minimum Data Set (MDS), with an Assessment Reference Date of 06/08/2024, revealed Resident #26 had a Brief Interview for Mental Status (BIMS) of 13, which indicated the resident had intact cognition. The MDS indicated the resident was dependent upon staff for most activities of daily living, had an indwelling catheter, and one unstageable pressure ulcer.
Resident #26's care plan initiated on 06/07/2021, indicated the resident had a reopened stage 4 pressure ulcer on their coccyx related to a history of ulcers and immobility. The resident also had another care plan, initiated on 03/11/2022, that indicated the resident had an indwelling catheter related to a diagnosis of neurogenic bladder.
During an observation on 06/18/2024 at 1:42 PM, Certified Nurse Aide (CNA) #1 emptied Resident #26's indwelling catheter bag. CNA #1 wore gloves and did not put on a gown.
During an observation on 06/18/2024 at 1:45 PM, CNA #2 provided incontinence care for Resident #26. can #2 wore gloves and a mask, but did not put on a gown.
During an observation on 06/18/2024 at 1:50 PM, Licensed Vocational Nurse (LVN) #3 performed wound care for Resident #26. LVN #3 wore gloves during the wound care, but did not put on a gown.
During an interview on 06/18/2024 at 2:14 PM, CNA #2 stated she was not required to use enhanced barrier precautions when she provided incontinence care for Resident #26.
During an interview on 06/18/2024 at 2:16 PM, LVN #3 stated she was not required to use enhanced barrier precautions for the wound treatment. LVN #3stated she believed enhanced barrier precautions would be required for emptying a catheter bag and for the provision of care for a resident who had a feeding tube.
During an interview on 06/18/2024 at 2:18 PM, CNA #1 stated she was not required to use enhanced barrier precautions when she provided incontinence care or emptied a catheter bag unless the resident was in isolation and had signs on their door.
During an interview on 06/19/2024 at 8:59 AM, the Infection Preventionist (IP) stated all three of the staff should have worn gloves and a gown for enhanced barrier precautions when they provided care for Resident #26. The IP stated the facility followed the Enhanced Standard Precautions for Skilled Nursing Facilities (SNF), 2019 developed by the California Department of Public Health.
During an interview on 06/20/2024 at 10:09 AM, the Administrator stated she knew staff wore personal protective equipment as required and would expect them to wear a gown for enhanced barrier precautions when necessary.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure residents' rooms measured at least 80 square (sq) feet (ft) per resident in 6 (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]) of 16 resident rooms in the facility.
Findings included:
The facility request for renewal of waiver for room size, dated 06/17/2024, revealed the following dimensions:
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In room [ROOM NUMBER], there was 78.42 sq ft for each resident.
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In room [ROOM NUMBER], there was 78.42 sq ft for each resident.
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In room [ROOM NUMBER], there was 77.59 sq ft for each resident.
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In room [ROOM NUMBER], there was 77.59 sq ft for each resident.
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In room [ROOM NUMBER], there was 77.59 sq ft for each resident.
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In room [ROOM NUMBER], there was 77.59 sq ft for each resident.
During an interview on 06/20/2024 at 10:04 AM, the Director of Nursing stated the facility had a room size variance waiver in place for the rooms that provided less than the required 80 sq ft per resident.
During an interview on 06/20/2024 at 10:30 AM, the Administrator stated she expected staff to treat the residents in the room with the room size variance waiver the same as all other residents in terms of quality of care and services.

Based on interview, record review, document review, and facility policy review, the facility failed to act upon the Consultant Pharmacist's recommendation for 2 (Resident #2 and Resident #32) of 5 sampled residents reviewed for unnecessary medications.
Findings included:
A facility policy titled, Consultant Pharmacist Reports, effective date 06/2021, revealed, The consultant pharmacist performs a comprehensive medication regimen review (MRR) at least monthly. The MRR includes evaluating the resident's response to medication therapy to determine that the resident maintains the highest practicable level of functioning and prevents or minimizes adverse consequences related to medication therapy.
1. An admission Record revealed the facility admitted Resident #2 on 11/15/2023. According to the admission Record, the resident had a medical history that included a diagnosis of heart failure.
A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/23/2024, revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition.
Resident #2's Order Summary Report with active orders as of 06/19/2024, revealed an order dated 11/30/2023 for mometasone furoate inhalation aerosol 200 micrograms per actuation 2 puffs inhale orally twice daily for asthma.
The Consultant Pharmacist's Medication Regimen Review, for recommendations created between 05/01/2024 and 05/05/2024, revealed please add to Resident #2 order for mometasone rinse mouth with water after use, do not swallow the water.
2. An admission Record revealed the facility admitted Resident #32 on 01/17/2024. According to the admission Record, the resident had a medical history that included a diagnosis of hypertension.
A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/24/2024, revealed Resident #32 had a Brief Interview for Mental Status (BIMS) score of 7, which indicated the resident had severe cognitive impairment.
Resident #32's Order Summary Report with active orders as of 06/20/2024, revealed an order dated 03/05/2024 for Eliquis oral tablet 2.5 milligrams (mg) (apixaban) give one tablet by mouth two times a day for deep vein thrombosis prophylaxis.
The Consultant Pharmacist's Medication Regimen Review, for recommendations created between 05/01/2024 and 05/05/2024, revealed Resident #32 had an order for apixaban and the Consultant Pharmacist recommended the facility add shift monitoring to detect any bleeding.
Resident #32's Medication Administration Record for 06/2024, revealed evidence to indicate staff monitored Resident #32 for bleeding prior to 06/20/2024.
In an interview on 06/20/2024 at 8:29 AM, the Director of Nursing (DON) stated he started the position of DON on 05/01/2024. The DON stated he had not gotten the Consultant Pharmacist's MRR for May 2024. According to the DON, the Consultant Pharmacist recommendations for Resident #2 and Resident #32 had not been acted upon.
In an interview on 06/20/2024 at 10:06 AM, the Consultant Pharmacist stated the recommendation should have been addressed by now.
In an interview on 06/20/2024 at 10:46 AM, the Administrator stated staff should update a resident's physician order with recommendations from the Consultant Pharmacist.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure 6 (Rooms 26, 27, 29, 31, 33, and 35) of 16 resident bedrooms in the facility did not have more than four residents.
Findings included:
The facility Daily Census, dated 06/17/2024, revealed five residents resided in room [ROOM NUMBER] and room [ROOM NUMBER] and six residents resided in Rooms 27, 29, 31, and 33.
During an interview on 06/20/2024 at 10:04 AM, the Director of Nursing stated the facility had a room variance waiver in place for the rooms that had more than four occupied beds.
During an interview on 06/20/2024 at 10:30 AM, the Administrator stated she expected staff to treat the residents in the rooms with more than four beds the same as all other residents in terms of quality of care and services.

Based on observation, record review, interview, document review, and facility policy review, the facility failed to ensure a medication error rate of less than 5%. The facility had 4 medication errors out of 26 opportunities, which yielded a medication error rate of 15.38% for 1 (Resident #40) of 4 residents observed for medication administration.
Findings included:
A facility policy titled, Medication Administration Oral Inhalations, dated 05/2016, indicated, 14. If another puff of the same or different medication is required, follow the manufacturer's product information for administration instructions including the acceptable wait time between inhalations.
The undated Dulera Patient Information, revealed, 10. Wait at least 30 seconds to take your second puff of Dulera.
A facility policy titled, Medication Administration General Guidelines, dated 09/2018, indicated, Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication. Per the policy, 1. Medications are administered in accordance with written orders of the prescriber.
An admission Record indicated the facility admitted Resident #40 on 12/13/2022. According to the admission Record, the resident had medical history that included a diagnosis of amyotrophic lateral sclerosis (ALS).
Resident #40's Order Summary Report, with active orders as of 06/19/2024, revealed an order dated 08/09/2023, for Dulera (a medication used to treat asthma) Aerosol 200-5 micrograms per action, inhale two puffs two times daily to decrease inflammation in the lungs. The Order Summary Report revealed an order dated 12/13/2022, for omega-3 fatty acid capsule (a medication used to lower triglyceride levels in adults) 500 milligrams by mouth daily for cholesterol control; Peridex Solution (an antiseptic mouthwash used to treat gingivitis) 0.12%, give 15 milliliters every 12 hours for oral care; and riluzole (a prescription medication used for the treatment of ALS) 50 mg one tablet by mouth every 12 hours related to ALS.
During a medication administration observation on 06/18/2024 at 9:07 AM, Licensed Vocational Nurse (LVN) #1 administered one puff of the Dulera to Resident #40 followed by a second puff five seconds later. LVN #1 did not administer omega-3 fatty acid capsule, riluzole, or the Peridex Solution to Resident #40 during the medication administration observation.
During an interview on 06/18/2024 at 12:11 PM, LVN #1 stated she did not administer the omega-3 fatty acid, riluzole, or the Peridex Solution to Resident #40. LVN #1 confirmed she did not wait at least 30 seconds to administer the second puff of Dulera to Resident #40.
During an interview on 06/18/2024 at 12:45 PM, the Director of Nursing stated he expected staff to administer medications according to the physician's orders and per the manufacturer's instructions.
During an interview on 06/20/2024 at 10:18 AM, the Administrator stated she expected staff to administer medications according to the physician's orders and per the manufacturer's instructions.

Based on interview, record review, and facility policy review, the facility failed to transcribe a physician's order for wound care for 1 (Resident #2) of 14 sampled residents.
Findings included:
A facility policy titled, Wound Care, revised in10/2010, revealed, The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Preparation 1. Verify that there is a physician's order for this procedure.
An admission Record revealed the facility admitted Resident #2 on 11/15/2023. According to the admission Record, the resident had a medical history that included a diagnosis of heart failure.
A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/23/2024, revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition.
Resident #2's care plan, initiated on 11/16/2023, revealed the resident had potential/actual skin impairment to skin integrity related to suspected deep tissue injury.
Resident #2's Surgical Consult dated 06/12/2024, revealed the physician was asked to see the resident for their opinion on how to manage the resident's wound located on the left inferior knee. The Surgical Consult revealed the wound dressing used was gentamicin (an antibiotic used to treat skin infections), Bactroban (an antibiotic used to treat skin infections), skin prep, and boarded foam. According to the Surgical Consult, the resident's wound was stable and required continued topical wound dressing as noted above.
Resident #2's Order Summary Report, with active orders as of 06/19/2024, revealed no order no order for the provision of wound care to the resident's left inferior knee.
In an interview on 06/19/2024 at 3:46 PM, the Wound Physician stated Resident #2 had been on topical antibiotics for weeks. The Wound Physician stated that on 06/12/2024 she ordered gentamicin, Bactroban, skin prep, and boarded foam for the resident. The Wound Physician stated she expected the orders to be transcribed into the resident's medical record by the next day shift unless it was a renewal and it was already covered. The Wound Physician stated she did not know what happened or why there were not any wound care orders for the resident. According to the Wound Physician, the treatment nurse should transcribe the orders after rounds.
In an interview on 06/20/2024 at 12:58 PM, the Director of Nursing (DON) stated the Wound Physician directed the residents' wound care and the staff were directed to follow their orders. The DON stated the treatment nurse should receive the order and transcribe the order into the resident's electronic medical record (EMR).
In an interview on 06/20/2024 at 1:13 PM, Licensed Vocational Nurse (LVN) #3 stated she performed wound care for Resident #2 daily. Per LNV #3, the wound treatment she provided was gentamicin and Bactroban ointment and covered the wound with foam dressing. LVN #3 stated she failed to transcribe the physician's order for wound care to the resident's EMR that was given to her by the Wound Physician.
In an interview on 06/20/2024 at 1:41 PM, the Administrator stated staff should process and implement treatment orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to administer the medication Tramadol 50 mg (medication used to help relieve moderate to moderately severe pain) as per physician ' s order for one (Resident 1) of three sampled residents.
This failure resulted in Resident 1 receiving a double dose of medication within 12 hours and placed Resident 1 ' s health and safety at risk.
Findings:
During a review of Resident 1 ' s admission record, printed on 11/1/23, the admission record indicated Resident 1 was originally admitted to the facility on [DATE].
During a review of Resident 1 ' s physicians orders dated 8/15/23, the physician orders indicated to administer Tramadol HCL oral tablet 50 mg, 1 tablet every 12 hours as needed for pain.
During a review of Resident 1 ' s Antibiotic and Controlled Drug Record, dated 8/30/23, the controlled drug record indicated on 9/20/23, Tramadol was taken out of the medication cart at 10:15 p.m. and signed by licensed nurse. The controlled drug record also indicated Tramadol was taken out of the medication cart at 2:21 am on 9/21/23 and signed by licensed nurse.
During a concurrent interview and record review on 11/1/23, at 1:08 p.m. with Licensed Vocational Nurse (LVN) 1, Resident 1 ' s Medication administration record (MAR), for [DATE] was reviewed. LVN 1 stated that the MAR indicated Tramadol was administered on 9/21/23 at 2.16 a.m. LVN 1 stated there was no record of Tramadol administered at 10:15 pm on 9/20/23 in the electronic health record.
During an interview on 11/1/23, at 2:22 p.m. with Registered Nurse (RN) 1, RN 1 stated on 9/20/23 she administered the medication Tramadol 50 mg orally to Resident 1 at 10:15 pm. RN 1 stated after administering the medication she forgot to click the save in electronic health record and the medication administration was not registered in the system accurately. RN 1 stated this allowed the night shift nurse to administer medication again before it was due. RN 1 stated it is very important to document medication administration correctly to prevent residents getting double doses and can be dangerous.
During an interview on 11/1/23 at 2:35 p.m. with Director of Nursing (DON), DON stated it is critical to accurately document medication administration as it is the proof that the medication was given and a way of communication to the other nurses. DON stated when medication administration is not documented correctly there is a high risk for medication error with possibility to cause adverse effects and permanent complications.
During a review of the facility ' s undated policy and procedure (P&P) titled, Medication administration, the P&P indicated, To administer oral medication in an organized, accurate and safe manner .Chart medication administration on Medication Administration Record immediately following each resident ' s medication administration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide supervision and maintain safety to prevent an avoidable accident for one of three sampled residents (Resident 1) when Certified Nurse Assistant (CNA) 1 provided Resident 1 two instant hot packs (a chemically activated disposable pack squeezed to pop an inner fluid bag and shaken to produce heat) without a physician order or protective barrier. Resident 1 placed the hot packs directly on her abdomen and was not supervised or reassessed during the application.
This failure caused a second-degree burn (a burn that damages the outer layer [dermis] and second layer [epidermis] of skin) on Resident 1's lower abdomen.
Findings:
During a review of Resident 1's admission Record dated 9/8/23, the admission Records showed Resident 1 was admitted in May 2022.
During a review of Resident 1's Minimum Data Set (MDS - an assessment used to guide care) assessment dated [DATE], Section C showed a Brief Interview for Mental Status (BIMS - an assessment tool used to evaluate mental status) score of 15 out of 15, indicating intact mental status. Resident 1 was wheelchair bound and Section G of the MDS showed her functional status included needing extensive assistance transferring and independent when moving about the unit once in her wheelchair. Section M of the MDS showed Resident 1 had intact skin but was at risk for developing pressure ulcers/injuries and had moisture-associated skin damage.
During an interview on 9/8/23 at 12:30 p.m. with Resident 1, Resident 1 stated she asked Certified Nurse Assistant (CNA) 1 for hot packs on 8/25/23 because she had menstrual cramps. Resident 1 stated CNA 1 'broke them and handed two hot packs to her. Resident 1 further stated she took the hot packs to her room and placed them on her abdomen for 30 45 minutes. Resident 1 removed the hot packs when she repeatedly felt moisture and stinging. Resident 1 stated she went to the nurses station to ask the nurses what was on her abdomen and they told her she had a burn. Resident 1 stated her pain was 8/10. Resident 1 further stated Licensed Vocational Nurse (LVN) 1 applied medicine and covered the wound after calling the doctor.
During an interview on 9/8/23 at 3:10 p.m. with CNA 1, CNA 1 stated Resident 1 asked for two hot packs at approximately 7 p.m. on 8/25/23. CNA 1 stated she asked Licensed Vocational Nurse (LVN) 2 and was instructed to check the closet in Station 2. CNA 1 stated she activated the hot packs, placed them on a medication cart shelf at Station 2, and told Resident 1 to wait while she got towels. CNA 1 stated she was gone approximately 15 minutes and when she returned, Resident 1 was found in her room with nurses caring for a burn on Resident 1's abdomen. CNA 1 stated she didn't know if Resident 1 had an order for hot packs but assumed it was okay since LVN 2 told her to get the hot packs.
During a concurrent observation and interview on 9/8/23 at 3:17 p.m. with Licensed Vocational Nurse (LVN) 1 in Resident 1's room, Resident 1's abdominal wound was observed during a dressing change. LVN 1 stated the wound measured 5 cm x 12 cm. The lower abdominal wound was midline and extended to the right. The wound had pink margins and a white wound bed with two grayish-tan areas, one in the middle of the wound and one to the left. In addition, there were two small, approximately 0.5 cm x 0.5 cm dried, dark brown blisters located just inferior and to the left of Resident 1's umbilicus (belly button).
During a telephone interview on 9/8/23 at 4:33 p.m. with Licensed Vocational Nurse (LVN) 2 and Director of Nursing (DON) present, LVN 2 stated she was the charge nurse on 8/25/23, the evening of Resident 1's injury. LVN 2 stated CNA 1 did not ask her to use hot packs for Resident 1. LVN 2 further stated Resident 1 did not have an order for hot packs, and she previously told Resident 1 to drink warm water to help relieve her cramping. LVN 2 stated hot packs required a physician order and application by licensed nurses only.
During an interview on 9/8/23 at 4:42 p.m. with DON, DON stated Resident 1 did not have a physician order for hot packs. DON also stated hot packs fell under the facility's Hot Compress Policy and a physician order was required. DON further stated facility staff are expected to follow the manufacturer's instructions on the hot pack packaging.
During a phone interview on 9/21/23 at 2:50 p.m. with Resident 1's doctor (MD 1), MD 1 stated he never ordered hot packs for Resident 1, nor was he called for an order. MD 1 also stated he would have ordered ibuprofen (medication that reduces inflammation) rather than hot packs as treatment for menstrual cramps if he had been called. MD 1 stated Resident 1's diabetes (a disease that impairs the way the body uses blood sugar) caused her decreased sensation and may have contributed to Resident 1's burns.
During a review of the facility's Incident Investigation Summary, undated, the Investigation Summary indicated on 8/25/23, Resident 1 had an open abdominal wound that measured 5 cm x 12 cm x 0.1 cm caused by two hot packs applied directly to her abdomen. The Investigation Summary also indicated CNA 1 said she was unaware she can't apply items like a heat pack on residents and only a nurse can do so. The Investigation Summary further indicated, Supply of heat packs removed from a nursing supplies closet to allow only licensed personnel to access.
During a review of the facility's policy and procedure (P&P) titled, Compress or Soak, Applying Warm, dated 2/2018, the P&P indicated, 1. Verify there is a physician's order for this procedure. 2. Review the resident's care plan to assess for any special needs of the resident. 3. Assemble the equipment and supplies as needed.
During a review of [NAME] Instant Disposable Hot Compress packaging, undated, the package indicated, Peak temperature may reach 160?. Do not apply directly to skin, wrap in towel or cloth for protection. Do not use for more than 30 minutes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to meet professional standards for care for one of three residents (Resident 1) when Certified Nurse Assistant (CNA) 1 provided Resident 1 two instant hot packs (a chemically activated disposable pack squeezed to pop an inner fluid bag and shaken to produce heat) without a physician order or protective barrier. Resident 1 placed the hot packs directly on her abdomen and was not supervised or reassessed during the application.
This failure caused a second-degree burn (a burn that damages the outer layer [dermis] and second layer [epidermis] of skin) on Resident 1's lower abdomen.
Findings:
During a review of Resident 1's admission Record dated [DATE], the admission Records showed Resident 1 was admitted in [DATE].
During a review of Resident 1's Minimum Data Set (MDS - an assessment used to guide care) assessment dated [DATE], Section C showed a Brief Interview for Mental Status (BIMS - an assessment tool used to evaluate mental status) score of 15 out of 15, indicating intact mental status. Resident 1 was wheelchair bound and Section G of the MDS showed her functional status included needing extensive assistance transferring and independent when moving about the unit once in her wheelchair. Section M of the MDS showed Resident 1 had intact skin but was at risk for developing pressure ulcers/injuries and had moisture-associated skin damage.
During an interview on [DATE] at 12:30 p.m. with Resident 1, Resident 1 stated she asked Certified Nurse Assistant (CNA) 1 for hot packs because she had menstrual cramps. Resident 1 stated CNA 1 'broke them and handed two hot packs to her. Resident 1 further stated she took the hot packs to her room and placed them on her abdomen for 30 45 minutes. Resident 1 removed the hot packs when she repeatedly felt moisture and stinging. Resident 1 stated she went to the nurses station to ask the nurses what was on her abdomen and they told her she had a burn. Resident 1 stated her pain was 8/10. Resident 1 further stated Licensed Vocational Nurse (LVN) 1 applied medicine and covered the wound after calling the doctor.
During a concurrent interview and record review on [DATE] at 1:02 p.m. with Director of Nursing (DON), CNA 1's California Department of Public Health Nurse Assistant Certification, dated [DATE], was reviewed. The certificate indicated CNA 1's Nurse Assistant certification expired [DATE]. DON stated CNA 1 was registry staff and provided an orientation binder specific to registry on her start date. DON also stated registry staff were required to sign an acknowledgement they reviewed the orientation binder. DON provided an email from CNA 1's employer, dated [DATE], and stated CNA 1 started at the facility on [DATE]. DON further stated she expected certified nurse assistants, including registry, to do shift-to-shift handoff (the transfer of resident information and status from one staff to another between shifts) and go to the charge nurse for any questions. Staff inservices (training/information provided at work) completed in 2023 were also reviewed. CNA 1 attended two of five inservices provided for certified nurse assistants, one on [DATE] for razor disposal, and one on [DATE] for heat packs provided after Resident 1's injury. DON stated no prior inservices for hot packs had been provided.
During an interview on [DATE] at 2:43 p.m. with Certified Nurse Assistant (CNA) 2, CNA 2 stated hot and cold packs required permission from the charge nurse. She stated she had applied hot and cold packs on residents before and used a towel to protect the resident's skin from getting too hot or too cold.
During an interview on [DATE] at 2:59 p.m. with Licensed Vocational Nurse (LVN) 3, LVN 3 stated hot packs required a physician's order and were only applied by the charge nurse. LVN 3 also stated hot packs were wrapped in a cloth or towel, and the nurse assessed whether the resident held the hot pack.
During an interview on [DATE] at 3:10 p.m. with CNA 1, CNA 1 stated Resident 1 asked for two hot packs. CNA 1 stated she asked Licensed Vocational Nurse (LVN) 2 and was instructed to check the closet in Station 2. CNA 1 stated she activated the hot packs, placed them on a medication cart shelf at Station 2, and told Resident 1 to wait while she got towels. CNA 1 stated she was gone approximately 15 minutes and when she returned, Resident 1 was found in her room with nurses caring for a burn on Resident 1's abdomen. CNA 1 stated she didn't know if Resident 1 had an order for hot packs but assumed it was okay since LVN 2 told her to get the hot packs.
During a concurrent observation and interview on [DATE] at 3:17 p.m. with Licensed Vocational Nurse (LVN) 1 in Resident 1's room, Resident 1's abdominal wound was observed during a dressing change. LVN 1 stated the wound measured 5 cm x 12 cm. The lower abdominal wound was midline and extended to the right. The wound had pink margins and a white wound bed with two grayish-tan areas, one in the middle of the wound and one to the left. In addition, there were two small, approximately 0.5 cm x 0.5 cm dried, dark brown blisters located just inferior and to the left of Resident 1's umbilicus (belly button).
During a telephone interview on [DATE] at 4:33 p.m. with Licensed Vocational Nurse (LVN) 2 and Director of Nursing (DON) present, LVN 2 stated she was the charge nurse the evening of Resident 1's injury. LVN 2 stated CNA 1 did not ask her to use hot packs for Resident 1. LVN 2 further stated Resident 1 did not have an order for hot packs, and she previously told Resident 1 to drink warm water to help relieve her cramping. LVN 2 stated hot packs required a physician order and application by licensed nurses only.
During an interview on [DATE] at 4:42 p.m. with DON, DON stated Resident 1 did not have a physician order for hot packs. DON also stated hot packs fell under the facility's Hot Compress Policy and a physician order was required. DON further stated facility staff are expected to follow the manufacturer's instructions on the hot pack packaging.
During an interview on [DATE] at 5:03 p.m. with DON, DON stated they could not provide CNA 1's signed orientation binder acknowledgement.
During a phone interview on [DATE] at 2:50 p.m. with Resident 1's primary physician (MD 1), MD 1 stated he never ordered hot packs for Resident 1, nor was he called for an order. MD 1 also stated he would have ordered ibuprofen (medication that reduces inflammation) rather than hot packs as treatment for menstrual cramps if he had been called. MD 1 stated Resident 1's diabetes caused her decreased sensation and may have contributed to Resident 1's burns.
During a review of the facility's Incident Investigation Summary, undated, the Investigation Summary indicated on [DATE], Resident 1 had an open abdominal wound that measured 5 cm x 12 cm x 0.1 cm caused by two hot packs applied directly to her abdomen. The Investigation Summary also indicated CNA 1 said she was unaware she can't apply items like a heat pack on residents and only a nurse can do so. The Investigation Summary further indicated, Supply of heat packs removed from a nursing supplies closet to allow only licensed personnel to access.
During a review of the facility's policy and procedure (P&P) titled, Compress or Soak, Applying Warm, dated 2/2018, the P&P indicated, 1. Verify there is a physician's order for this procedure. 2. Review the resident's care plan to assess for any special needs of the resident. 3. Assemble the equipment and supplies as needed.
During a review of [NAME] Instant Disposable Hot Compress packaging, undated, the package indicated, Peak temperature may reach 160?. Do not apply directly to skin, wrap in towel or cloth for protection. Do not use for more than 30 minutes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement written policies and procedures (P&P) that prevent abuse, neglect, and exploitation of residents when registry Certified Nursing Assistants (CNAs) were not given abuse training/orientation prior to working with residents.
This failure had the potential to result in abuse of residents.
Findings:
During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was re-admitted to the facility on [DATE] with diagnoses that included muscle weakness, end stage kidney disease, and high blood pressure.
During a review of Resident 1's Progress Notes, dated 9/4/23, the Progress Notes indicated Resident 1 complained of eight of 10 (0 for no pain and 10 as the most painful) pain on the back of her head after being transferred from the chair to the bed by CNA 1 and she hit her head on the headboard. The Progress Notes indicated Resident 1 had a round contusion at the back of the head that measured half an inch, Resident 1's daughter requested for Resident 1 to be transferred to the hospital for further evaluation.
During a review of the History & Physical (H&P), printed 9/7/23, the H&P indicated Resident 1 had a closed head trauma from the incident.
During an interview on 9/21/23 at 11:10 a.m. with Director of Nursing (DON), DON stated CNA 1 was assigned to Resident 1 on 9/4/23. DON stated CNA 1 was interviewed and gave a version of the incident that was different from Resident 1's account. DON stated CNA 1 was a registry staff and not a regular employee of the facility.
During another interview on 9/21/23 at 11:50 a.m. with DON, DON stated the registry does not provide documentation of abuse training for the registry staff that they send to the facility. DON stated registry staff are given orientation on abuse prevention before they start their first shift. DON stated an Orientation Binder for Registry Nurses and CNAs where orientation acknowledgment forms were filed.
During a review of the facility's undated Orientation Acknowledgement, the Orientation Acknowledgement indicated I .with staffing agency have reviewed the Registry Orientation Binder with a [facility staff] which include abuse, hoyer lift (mobility tool used to help seniors with mobility challenges get out of bed or the bath) and resident profiles . The Orientation Acknowledgment form would have the registry staff signature and facility staff signature.
During a concurrent interview and record review on 9/21/23 at 11:59 a.m. with Staff Scheduler (SS), the Staffing Schedule was reviewed. SS stated CNA 1, CNA 2 and CNA 3 worked the morning shift, all three CNAs were registry staff who worked on 9/4/23. SS stated CNA 4, also a registry staff who was on the schedule for 9/21/23, was at the facility during the investigation.
During an interview on 9/21/23 at 12:01 p.m. with CNA 4, CNA 4 stated being told where to find things and equipment during the first time at the facility but was not given abuse training.
During an interview on 9/21/23 at 12:33 p.m. with DON, DON stated there was no documentation that indicated CNA 1, CNA 2, CNA 3, and CNA 4 had abuse training/orientation in the Orientation Binder for Registry Nurses and CNAs.
During a review of the facility's P&P titled Abuse Prevention Program, last revised, December 2016, the P&P indicated for resident abuse prevention, the administration will protect the residents from abuse by anyone including, but not limited to, facility staff and staff from other agencies. The administration will require training/orientation that include abuse prevention, identification, and stress management.

Based on observation and interview, the facility had seven resident's rooms (Rooms A, B, C, D, E, F, G and H) with multiple beds that provided less than 80 square feet (sq.ft) per resident who occupied these rooms.
This deficient practice had the potential to result inadequate space for the delivery of care to each of the residents in each room, or for storage of the residents' belongings.
Findings:
During an observation on 6/7/21, at 10:00 a.m.,. the following rooms and corresponding square footage per bed were identified:
Room number A and B has three beds, total SQF is 235.30 and SQF per bed is 78.42.
Room number C has five beds and total SQF is 463.33 and SQF per bed is 97.41.
Room number D, E, F and G has six beds, total SQF is 465.60 and SQF per bed is 77.59.
Room number H has five beds and total SQF is 406.28 and SQF per bed is 86.43.
During random observation of care and services from 6/7/21 to 6/10/21 there was sufficient space for the provision of care for the residents in all rooms. There was no heavy equipment kept in the rooms that might interfere with resident's care and each resident had adequate personal space and privacy. There were no complaints from the residents regarding insufficient space for their belongings. There were no negative consequences attributed to the decreased space and/or safety concerns the eight rooms. Granting of room size waiver recommended.

4. During a review of the employee symptoms screening log in the presence of the Director of Nursing (DON), three staff members CNA 4, 5 and 6 were not screened for COVID-19 symptoms on Sunday 6/6/21 prior to providing care for residents.
During an interview on 6/09/21, at 8:54 a.m., the DON stated screening logs are checked by the Medical Record Designee (MRD) who is responsible for collecting the forms.
During an interview on 6/09/21, at 8:47 a.m., MRD stated she only collects and keep the screening logs. MRD stated I do not verify for accuracy.
During an interview on 6/09/21, at 10:11 a.m., the Administrator (Admin) stated she was responsible for verifying that all staff are screened for COVID-19 symptoms prior to proving residents care.
The facility's policy and procedures, titled, COVID-19: Clinical Protocol undated, indicated All staff will be required to answer screening questionnaire and have their temperature checked before the beginning of each shift or start of work.
Based on observation, interview and record review the facility failed to provide a safe and sanitary environment for four (Residents 21, 26, 36, and 255) of 57 sampled residents, as evidenced by:
1) Nurse did not disinfect and clean BP cuff between using the BP cuff on residents 26, 36, 255
2) Nurses did not follow manufacturer's directions for SaniWipe use on medication baskets
3) Certified Nursing Assistant did not perform hand hygiene after doffing gloves and assisting a resident
4) The facility did not screen staff members for COVID-19 symptoms on 6/6/21 prior to providing care for the residents.
.
These failures had the potential to result in cross contamination and infection.
Findings:
1. During an observation on 6/8/21, at 8:35 am., Registered Nurse (RN)2 removed wrist blood pressure (BP) cuff from his own wrist and placed it directly on the left wrist of Resident 255. After measuring Resident 255 BP. RN 2 removed the BP cuff from Resident 255's wrist and placed it back on his wrist. The BP cuff was not cleaned or disinfected prior to or after use with Resident 255.
During an observation on 6/8/21, at 8:50 a.m., RN 2 removed wrist BP cuff from his own wrist and placed it directly on the left wrist of Resident 36. The BP cuff was not cleaned or disinfected prior to or after use with Resident 36.
During an observation on 6/8/21, at 9:10 a.m., RN 2 removed wrist BP cuff from his own wrist and placed it directly on the left wrist of Resident 26. The BP cuff was not cleaned or disinfected prior to or after use with Resident 26.
During an interview on 6/10/21, at 7:30 a.m., with RN 2, RN 2 stated the wrist BP cuff is from his personal home, and that he cleaned the wrist BP cuff after his shift and not between residents. RN 2 stated if a resident was on isolation he would clean between residents but not if the residents are not on isolation. RN 2 stated he was unsure if the facility had a policy that stated he needed to clean the BP cuff between resident use.
During an interview on 6/10/21, at 8 a.m., with the DON, the DON stated BP cuffs are to be cleaned between resident use to maintain infection control.
During a review of the facility's policy and procedure titled, Cleaning and Disinfection of Resident-Care Items and Equipment, dated 7/2014, it indicated, Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA Bloodborne Pathogens Standard, and Reusable items are cleaned disinfected or sterilized between residents.
2. During an observation on 6/8/21, at 8:45 a.m. and 9:05 a.m., Registered Nurse (RN) 2 wiped the medication basket on the medication cart using Sani-Cloths, and immediately used the basket
During an observation on 6/8/21, at 9:45 a.m. and 10:10 a.m., Licensed Vocational Nurse (LVN) 2 wiped the medication basket on the medication cart using Sani-Cloths, and immediately used the basket.
During an concurrent observation and interview on 6/10/21, at 7:30 a.m. RN 2 stated he didn't look at the Sani-Cloth germicidal disposable wipe container regarding the wet time or kill time. RN 2 stated he had not read the Sani-Wipe guidelines.
During a review of the Sani-Wipe germicidal disposable wipe container on 6/9/21, at 8:10 a.m., it indicated to Allow surface to remain wet for three (3) minutes. Let air dry and Bactericidal, tuberculosis, virucidal in 3 minutes.
During a review of the facility's policy and procedure titled, Cleaning and Disinfection of Environmental Surfaces, dated June 2009, indicated Non-critical surfaces will be disinfected with an EPA-registered intermediate or low-level hospital disinfectant according to the label's safety precautions and use directions and By law, all applicable label instructions on EPA-registered products must be followed.
3. During an observation on 6/7/21, at 10:45 a.m., in Resident 5's room, Certified Nursing Assistant (CNA)1 touched the bedside commode (BSC), it's lid, seat and handles, that was located at the foot of Resident 5's bed. After CNA1 touched the BSC she doffed her gloves, then placed Resident 21's cup on the bedside table. CNA1 did not perform hand hygiene (HH) after she doffed her gloves.
During an interview on 6/7/21, at 10:50 a.m., with CNA 1, CNA 1 stated that she should have sanitized her hands after she doffed her gloves, and before she helped Resident 21.
During a review of handwashing in-services, dated 12/14/20 and 10/29/20, CNA 1 was signed-in at both in-services.
During a review of the facility's policy and procedure (P&P) titled, Handwashing/Hand Hygiene, dated August 2015, indicated This facility considers hand hygiene the primary means to prevent the spread of infections, and Use an alcohol-based hand rub . or alternatively soap . and water for the following situations:. After contact with blood or bodily fluids; l. after contact with objects (e.g. medical equipment) in the immediate vicinity of the resident;. After removing gloves and Hand Hygiene is the final step after removing and disposing of personal protective equipment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility record review, the facility failed to store food, brought into the facility by visitors, safely for residents. The facility also failed to have a policy to show food would be stored safely for residents upon request.
This failure had the potential for decreased food intake by residents who preferred to eat food brought in from outside sources for 56 residents who were able to eat food by mouth out of a facility census of 57.
Findings:
Review of the undated facility policy and procedure titled Food For Residents From Outside Sources showed food brought in from outside sources for the resident would first be shown to the charge nurse for approval to ensure the food was within the diet order parameters. The nurse would consult with the Food and Nutrition Supervisor (FNS) or the consultant dietitian as needed. Prepared or perishable food must be consumed within one hour of receiving . Unused food would be disposed of immediately thereafter.
An observation on 6/8/21 at 2:30 p.m. showed a carton of individual yogurt containers with room [ROOM NUMBER] E and Resident 22's name written on the carton located in a staff refrigerator. There was also a plastic bag with 25 C written on the bag. Inside the bag was a store-bought fruit salad in a plastic container. The fruit salad consisted of cut watermelon, cut cantaloupe, cut honey dew, cut pineapple, and grapes. There was no thermometer in the refrigerator to determine the internal ambient temperature of the refrigerator.
In a concurrent interview on 6/8/21 at 2:30 p.m., Licensed Vocational Nurse 1 (LVN 1) stated staff were not allowed to store food for residents brought in from visitors. She said there was no refrigerator to store this type of food. She confirmed the food labeled with resident names and room numbers were residents at the facility.
In an interview on 6/8/21 at 2:30 p.m., the Director of Nursing (DON) stated there was not a refrigerator to store food for residents brought in by visitors. She stated she worked at the facility for 5 months and never went upstairs to look in the staff break room refrigerator. She said food brought in from outside was not allowed but sometimes if a resident did not eat well it was allowed. She stated food was not allowed from outside because of concern with infection control as well as the possible contraindication with physician diet orders. She said she encouraged families to not bring in food for residents. The DON looked in the staff refrigerator and confirmed there was food inside labeled with resident name and room numbers. She stated the refrigerator was supposed to be only for staff food. She said nursing was not trained on storing food safely in refrigerators for residents. She said she did not know the appropriate storage temperature for refrigerated foods. The DON confirmed there was no thermometer in the staff refrigerator.
A concurrent observation on 6/8/21 at 2:30 p.m., showed the temperature of the melon in the fruit salad was 44 degrees Fahrenheit when measured with a calibrated digital thermometer.
In an interview on 6/8/21 at 2:54 p.m., Certified Nursing Assistant 3 (CNA 3) stated she was caring for resident 255 that day. She stated when she came in for her shift that morning the resident had food brought in by visitors at her bedside. CNA 3 stated there were 2 plastic containers of fruit salad and a vegetable platter. She labeled the bag that contained a fruit salad with the resident's room number and placed it in the staff refrigerator at 7:30 a.m. that morning. She left one fruit salad and the vegetable platter at the resident's bedside. She stated she did not know anything about safe food storage temperatures.
An observation and interview with resident 255 at 3 p.m., showed she had a vegetable platter and a plastic container of fruit salad. The fruit salad was half full. The resident stated a family member brought the food in for yesterday evening. She said she wanted to keep the fruit salad at her bedside and eat some more of it.
In an interview on 6/9/21 at 12:25 p.m., the RD stated no outside food was allowed for residents as long as she was the RD for the facility which was 5 years. She stated she was not aware of any training for nursing about safe food storage. She said yogurt should not be in the refrigerator if the refrigerator is not being monitored for temperatures. She also stated cut melon is a potentially hazardous (time temperature control for safety food; food that has an increased potential to grow bacteria if it is not stored safely.)
According to the 2017 Federal Food Code, Time/Temperature Control for Safety Food is to be held at 41 degrees F or less when time is not used as a control.

Based on observation, interview, and facility document review, the facility failed to serve two residents (Resident 51 and 49) of 57 sampled residents diets prescribed by a physician.
This failure had the potential for two residents, Resident 51 and 49, to receive inadequate calories and/or nutrients contraindicated for a prescribed diet leading to nutritional related health issues.
Findings:
1. An observation of trayline food service on 6/8/21, at 12 p.m., showed resident [NAME] 1 placed a scoop of mashed potatoes on a plate for resident 51's lunch. An observation of the tray ticket for Resident 51 located on his tray showed he was on a Regular, Controlled Carbohydrate (a diet typically prescribed to diabetics), Renal (a diet typically prescribed to a person with kidney disease), Thin Liquids.
During a review of the Cook's Spreadsheet titled Summer Menus Week 1 Tuesday and used for lunch on 6/8/21, showed residents on a renal diet received wheat pasta with margarine instead of mashed potatoes which was served to regular diets.
In a concurrent interview with [NAME] 1, the Registered Dietitian (RD) and the Dietary Supervisor (DS), on 6/8/21, at 12 p.m., the RD confirmed Resident 51 should have not received mashed potatoes because he was on a renal diet. The RD stated the diet for resident 51 was recently changed to Renal. DS stated [NAME] 1 was familiar with all the resident diets, so she did not read all the meal tickets and she missed the new diet change written on the Resident's meal ticket.
Review of the Diet Manual For Long Term Care and Residential Facilities 2020 reviewed and signed by the RD on 1/8/21, gave a description of a Renal diet which indicated, this diet is usually ordered when a patient is in renal failure, receiving dialysis, or has elevated serum potassium. Potassium content of the diet is controlled to prevent hyperkalemia (elevated blood potassium). An example of a menu for a Renal diet was given and indicated to avoid potatoes.
In an interview with RD on 6/9/21, at 12:25 p.m., the RD stated the diet order for Resident 51 was changed on Monday 6/7/21. She said the cook should have looked at the entire tray ticket during trayline. She stated the kitchen did not get the communication slip from the Director of Nursing (DON) that alerted the kitchen of a new diet. She stated the original communication slip was placed in the resident's chart and the carbon copy was given to the kitchen.
In an interview with DS on 6/10/21, at 8:42 a.m., DS stated cooks should look at the tickets when serving food on trayline. She stated sometimes, but not all the time, there was a kitchen staff to help the cook read the trayline tickets and make sure the food on the tray was correct for the prescribed diet.
In an interview with RD on 6/10/21, at 9:11 a.m., the RD stated she recommended Resident 51's diet change to a Renal diet based on his lab results.
Review of Resident the Nutrition/Dietary note dated 6/4/21, showed the RD stated Given recent lab results with elevated BUN (Blood urea nitrogen; a test used to measure the amount of nitrogen in the blood), Cr (Creatinine; a waste product removed from the body by the kidneys), and K+ (Potassium), recommend to change diet to Renal, CCHO, regular texture .
During a review of the facility's policy and procedure (P&P) titled, Diet Orders, dated 2018, the P&P indicated, Policy diet orders as prescribed by the physician will be provided by the food and nutrition services department. Nursing will send a Diet Order Communication slip to the Food and Nutrition Services department. The FNS Director or cook in charge will make or adjust the diet profile and tray card as prescribed Any discrepancy in the diet order slip will be clarified by the FNS Director or cook in charge with nursing.
During a concurrent interview and record review on 6/10/19 at 12:54 p.m., with DON, Resident 51's Status Report, dated 6/7/21, signed by DON, was reviewed. The status report showed a change to renal diet for Resident 51. DON stated this report is used to communicate diet change orders between nursing and dietary staff. DON stated she gave a dietary staff member the yellow carbon copy but could not remember which staff member.
During a review of the facility's Food and Nutrition Services (FNS) director job description, titled Job Description, Position FNS Director, dated 2018, the document indicated, [FNS] is responsible for the preparation and service of all food and ensures that approved menus and accompanying recipes are followed. In addition, the document indicated, [FNS is to] check trays to ensure diets are served as ordered.
During a review of the facility's policy and procedure (P&P) titled, Diet Orders, dated 2018, the P&P indicated, Policy diet orders as prescribed by the physician will be provided by the food and nutrition services department.
2.
During a concurrent observation and interview on 6/8/21, at 12:40 p.m., with CK 1, RD and DS, the preparation of Resident 49's lunch tray was observed. CK 1 plated mashed potatoes, gravy, shredded beef and spinach. CK 1 placed the plate on Resident 49's meal tray for delivery to Resident 49. The diet order card dated 6/8/21, on Resident 49's tray indicated , Diet order: Mech Soft (easy to chew and swallow food texture), Controlled Carbohydrate, Fortified Diet (foods with additional nutrients added), Thin liquids. CK 1 stated she fortified the meal with melted butter. Melted butter was not observed on Resident 49's meal. RD and DS confirmed residents with a fortified diet should have a scoop of melted butter added to the meal and the butter on Resident 49's meal was missed.
During a review of Resident 49's Diet Type Report, dated 6/10/21, the report indicated Resident 49 was on a fortified diet.
During a review of the facility's fortified diet menu, titled, Weekly Guideline for Summer 2021 - Week 1, undated, the document indicated for fortified Tuesday lunch, Potatoes: ½ ounce melted margarine. Vegetables ½ ounce melted margarine.
During an interview with RD, on 6/9/121, at 12:25 p.m., RD stated CK 1 should have followed the fortified spreadsheet to know what to provide on trayline. She stated Resident 49 was initially placed on a fortified diet due to being underweight and not eating very well. It was recommended for Resident 49 to stay on a fortified diet to maintain weight.
During a review of the facility's Food and Nutrition Services (FNS) director job description, titled Job Description, Position FNS Director, dated 2018, the document indicated, [FNS] is responsible for the preparation and service of all food and ensures that approved menus and accompanying recipes are followed. In addition, the document indicated, [FNS is to] check trays to ensure diets are served as ordered.
During a review of the facility's policy and procedure (P&P) titled, Diet Orders, dated 2018, the P&P indicated, Policy diet orders as prescribed by the physician will be provided by the food and nutrition services department.

Based on observation, interview, and facility document review, the facility failed to ensure competency of staff in the functions of the food and nutrition service when:
1. [NAME] 2 did not follow and properly document cooldown procedures for a time temperature control for safety (TCS) food (food that is more likely to grow harmful bacteria if not stored appropriately leading to foodborne illness);
2. [NAME] 1 did not appropriately demonstrate how to check the quaternary ammonia strength to clean food contact and nonfood-contact surfaces;
3. [NAME] 1 did not follow the menu for residents on a renal diet; and
4. Dietary Assistant 2 (DA2) did not appropriately demonstrate how to check the chlorine strength for the dish machine.
This lack of competency by kitchen staff had the potential to result in contamination of food leading to foodborne illness as well as residents receiving different nutrients as indicated on the planned menu.
Findings:
1. An observation during the initial kitchen tour on 6/7/21, at 10:30 a.m., showed a plastic bag filled with cooked white rice. The plastic bag was dated 6/6/21.
During a review of the Cool Down Log binder, it did not show any cool down entries for food for the month of June. There was one entry for cooling of rice on 3/6/21. This entry showed the first temperature was taken at 11 a.m. and was 140 degrees Fahrenheit (F). The next temperature was taken at 2 p.m. and was 48 degrees F. This was 3 hours between taking the first and second temperature. The instructions on the cool down log showed a two-step cool down process. The first step was to take the temperature of a food 2 hours or less after the food dropped to 140 degrees F. to ensure the food was 70 degrees F or less.
During an interview on 6/9/21, at 2:25 p.m., the Registered Dietitian (RD) confirmed there was no entry for rice on 6/6/21 but there should be if cooked rice was observed in the refrigerator dated 6/6/21. She stated the entry for rice cool down dated 3/6/21 was not documented appropriately to show safe cool down. She said the second temperature should have been recorded after 2 hours at 1 pm to ensure the food was cooled appropriately.
During an interview with [NAME] 2 on 6/10/21, at 9:11 a.m., she stated the entry dated 3/6/21 was the entry for the cool down of the rice cooled on 6/6/21. She stated she made a mistake when she wrote the date. She also stated the process for cooling food involved checking the temperature of the food every 2 hours to make sure it was cooling properly. She stated her first entry showed she checked the rice at 11 am and again at 2 pm. She stated the time between 11 a.m. and 2 p.m. was 2 hours so the rice was cooled appropriately
2. During an observation and interview with [NAME] 1 and the RD on 6/8/21, at 10:35 a.m., [NAME] 1 stated she was responsible for checking the quaternary ammonium solution (quat) strength for the red buckets used to clean food contact and nonfood-contact surface areas. She demonstrated how she tested the strength of the solution by filling a red bucket with quat and dipped a quat test strip in the solution for 4 seconds. When the surveyor asked how long she was supposed to hold the test strip in the solution, she stated 10 seconds. She tested again with a new strip and counted to ten out loud very fast. Again, she held the strip in the solution for 4 seconds. The RD confirmed she did not hold the test strip in the solution for 10 seconds. The strip turned a very dark green and when [NAME] 1 compared the strip to the color chart located on in the test strip container, she stated the color of the strip showed the concentration of the quat solution was 200 parts per million (ppm). The color chart showed 200 ppm was a mustard yellow color. The color of the strip was observed by 2 surveyors and both surveyors concluded in comparison to the color chart, the strip showed the strength of the solution was between 300 to 400 ppm. The RD also agreed the strip compared to the color chart was more than 200 ppm.
Review of the quat test strip instructions located inside the container of the quat strips showed to immerse for 10 seconds .
3. During an an observation during trayline food service on 6/8/21, at 12 p.m., showed [NAME] 1 plated white rice on trays for residents whose tray tickets showed they were prescribed a renal diet.
Review of the Cook's spreadsheet titled Summer Menus Week 1 Tuesday used for lunch on 6/8/21, showed renal diets received wheat pasta with margarine.
During an concurrent interview with [NAME] 1, the RD, and DS on 6/8/2,1 at 12 p.m., [NAME] 1 stated she made a mistake and did not cook pasta to serve to residents on a renal diet. DS stated there was pasta available, so the reason for [NAME] 1 not making pasta was not because they ran out. DS stated residents did not like whole wheat pasta. The RD stated [NAME] 1 did not ask her if she could substitute rice for pasta because the cooks knew that rice could be a substitute for pasta if needed. She stated in this case, the residents on a renal diet should have received wheat pasta since they had it in stock. She stated she knew that residents did not like whole wheat pasta, but they accepted regular wheat pasta.
4. In an observation and interview with the RD and DA2 on 6/8/21 at 10:40 a.m., DA2 stated he was responsible for checking dish machine sanitizer strength. He demonstrated how he checked the strength by running a metal bowl through a cycle. When it was finished, he placed a chlorine test strip on the surface of a metal bowl. The test strip turned a dark purple color. He compared the strip to the color chart located in the test strip container and stated it showed the strength of the chlorine sanitizer was 200 ppm and it should be between 100 to 200 ppm. He stated 50 ppm was not okay. The RD stated the chlorine sanitizer strength for the dish machine should be 50 to 100 ppm.
Review of the Dish Machine Temperature Log dated 2020 showed in the instruction the chlorine should be 50 to 100 ppm.

Based on observation, interview and facility document review, the facility failed to:
1. Ensure the Registered Dietitian (RD) supported the Dietary Supervisor (DS) in maintaining a clean and safe kitchen environment;
2. Ensure the Dietary Supervisor (DS) maintained a clean kitchen and clean equipment on a day-to-day basis; and
3. Involve the RD in the quality assurance and performance improvement (QAPI; a data driven and proactive approach to quality improvement), when food and nutrition services was involved.
This failure had the potential for contamination of food leading to foodborne illness for a highly susceptible population of 56 residents who received food from the kitchen out of a facility census of 57.
Findings:
1. During the Federal Recertification Survey from 6/7/21-6/10/21, multiple issues were identified inside the kitchen including cleanliness of the environment such as a significant amount of residue, dirt, and/or dust on windows, window screens, window shade, walls, vents, window air-conditioner unit, on the inside surface of cabinets holding clean cooking utensils, food carts, light switch and light switch covers, and imbedded residue in cracked floor tiles. In addition, it was identified that drywall was damaged throughout the kitchen, caulking along wall seems were crumbling, cabinet doors were worn with exposed particle board, and a drawer front surface was cracked.
In an interview on 6/8/21, at 9:25 a.m., the RD stated she conducted a monthly sanitation and food safety check. She said she did not report on her monthly inspection the following: the vent located above a reach-in freezer which she confirmed was covered with black residue and the surrounding wall and ceiling had black residue on the surface fanning out from the vent, the light switch and cover by the back door with imbedded black residue which she stated was dirty and dusty, the large support pole by the back door which she confirmed had dried orange drip marks covering a large portion of the surface, broken floor tiles with imbedded black residue, multiple windows in the food preparation area she confirmed had residue and dust around the perimeters and along the window ledge, the window blind she confirmed was dirty and had black residue on the surface but she stated never looked at the blind before, the window air/conditioner which she stated was dirty and covered with dust, the surface of the cabinet next to the stove which held cooking utensils such as pans, had a black residue on the linoleum that covered the shelf surface. She stated it was just scuffed until the residue scraped off onto a paper towel, then she confirmed the shelf was dirty. She also stated she did not report wood cabinets located under a preparation table with the bottom of the outer wood surface worn and cracked exposing particle board. She stated ideally the cabinets should be replaced. She stated she did not report the tall open tray carts which she confirmed had a build-up of thick black residue at the base above all the wheels, and the utility cart with food stored on top which she confirmed had imbedded black residue and stated it was dirty.
Review of the last 3 kitchen audits completed by the RD titled Sanitation and Food Safety Checklist dated 3/24/21, 4/30/21, and 5/28/21 showed areas on the report for the RD to assess for cleanliness and condition included but not limited to: all floors, storage devices for dishware, air-cooling system, ceiling vents, all painted surfaces, all windows and doors.
Review of the job description titled Consultant Dietitian with a revised date of 2019, showed the RD was responsible for supporting the Food and Nutrition Services Director in maintaining department standards of food service storage, preparation, safety, and delivery to residents. In addition, conducts food safety and sanitation inspections with recommendations for items not meeting standards.
Review of the document titled Sanitation dated 2018, showed all equipment shall be maintained as necessary and kept in working order. Also, all utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seam, cracks, and chipped areas.
2. During the Federal Recertification Survey from 6/7/21-6/10/21 multiple issues were identified inside the kitchen including cleanliness of the environment such as a significant amount of residue, dirt, and/or dust on windows, window screens, window shade, walls, vents, window air-conditioner unit, on the inside surface of cabinets holding clean cooking utensils, food carts, light switch and light switch covers, and imbedded residue in cracked floor tiles. In addition, it was identified that drywall was damaged throughout the kitchen, caulking along wall seems were crumbling, cabinet doors were worn with exposed particle board, and a drawer front surface was cracked.
In an interview on 6/8/2,1 at 9:25 a.m., the DS stated she did not know who was responsible for cleaning the support structure which was a cylindrical support structure from floor to ceiling of at least 10 inches in diameter. It had a rough, painted surface. The surface had orange drip marks on a large portion of the surface. She said the kitchen staff should be responsible for cleaning it and it needed to be cleaned. The DS also stated maintenance was responsible for cleaning a vent located above a reach-in refrigerator. The vent surface was covered with a thick, black, residue. The residue also fanned out on the surrounding wall and ceiling. The DS confirmed the vent and the surrounding area was very dusty and dirty. She said maintenance did not do rounds in the kitchen on a regular basis to check for things that had to be cleaned or fixed. In order for maintenance to clean or fix anything, she had to write it in her logbook, which maintenance checked daily.
In an interview and observation on 6/8/21, at 9:49 a.m., the DS stated a kitchen staff cleaned floor by mopping but the maintenance staff was responsible for deep cleaning things that kitchen staff could not do. An observation of the window air conditioner located in a food preparation area had a fuzzy, gray matter on the surface of accordion plastic that connected the air conditioner to the window. She stated maintenance was responsible for cleaning the air conditioner. She said the air conditioner was used every day and stated it was dusty and dirty but did not have it in her logbook for maintenance to clean.
On 6/8/21, at 10:31 a.m., in an interview with DS and Dietary Aide 2, DS confirmed 2 tall, metal resident meal tray carts were dirty. An observation showed the area at the base above the wheels of the cart had a thick layer of a thick black residue. DS wiped the black residue with a towel and a black residue came off onto a towel. She stated DA 2 was responsible for cleaning the carts. DA 2 confirmed he cleaned the carts by wiping them down with sanitizer after trays were delivered, but he did not clean the bases to try to remove the built-up residue.
In an interview and observation with the Maintenance Supervisor (MS) on 6/9/21, at 10:29 a.m., he stated he did not clean anything in the kitchen, and he was not responsible for cleaning vents. He stated he did clean the window screens once a month but from standing outside of the kitchen and hosing them off. MS confirmed the cabinets located under a food preparation table had a surface that was coming off and exposing the underneath particle board. He said it was not in good condition, so it had to be repaired. He also stated a drawer under the preparation table was cracked and had to be replaced. He said he was not aware of these things since they were not reported to him in the logbook. MS also stated he was not responsible for cleaning the window air conditioner.
In an interview with the Administrator on 6/9/21, at 3:10 p.m., she stated the janitor was to make sure every aspect of the kitchen was clean. She stated the janitor went into the kitchen one time per week, early in the morning, and did a deep cleaning. She stated he did things such as scrub and buff the floors. She stated the janitor was also responsible for keeping the baseboards clean. The Administrator stated MS was in charge of cleaning the air conditioner and changing the air conditioner filters in the kitchen.
In an interview on 6/9/21, at 4 p.m., Housekeeper 1 (HK1) stated he worked at the facility for 20 years and there was no deep cleaning done in the kitchen by housekeeping staff. He stated housekeeping staff was not allowed in the kitchen to clean. He said the one housekeeping staff that did deep cleaning in the kitchen left working for the facility about 8 years ago.
Review of the undated facility cleaning schedule titled Janitor did not showed public bathrooms were cleaned but did not show other areas within the kitchen were cleaned.
Review of the undated facility daily work schedule titled Housekeeping did not show any areas in the kitchen were cleaned.
In an interview on 6/10/21, at 8:42 a.m., DS stated she did not always check to see that staff cleaned areas they were responsible for on the cleaning schedule. She stated she was too busy.
Review of the document titled Dietary aid/Tuesday 11:00 - 2:00 pm Cleaning Schedule dated 1/5/2021 showed wipe windows on the schedule.
Review of the job description titled FNS [Food and Nutrition Supervisor] dated 2018, showed the DS was responsible for maintaining cleanliness of kitchen equipment.
Review of the document titled Sanitation dated 2018, showed all equipment shall be maintained as necessary and kept in working order. Also, all utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seam, cracks, and chipped areas.
3. An observation during the initial tour of the kitchen on 6/7/21, at 10:20 a.m., showed tile baseboards throughout the kitchen were missing or coming away from the wall. Where there was missing baseboard, the drywall was missing or not intact. (Refer to F-812) In addition, a large mixer with a bowl was observed. The inside surface of the bowl had a dark residue that covered the bottom surface.
In an interview on 6/7/21, at 10:30 a.m., the Dietary Supervisor (DS) stated the residue in the bowl was not removeable and she did not know what it was. She said it had to be replaced and it was in this condition for 6 years.
In an interview with the RD on 6/8/21, at 9:25 a.m., she stated she reported baseboards in disrepair on a regular basis on her monthly inspection report. She also stated she noticed the mixer bowl was in bad condition a couple of years ago and reported it consistently on the inspection report.
In a concurrent interview with the Maintenance Supervisor (MS) on 6/8/21, at 9:25 a.m., he stated he was not aware the baseboards were missing and coming off the wall because he did not see the RD reports.
Review of the last 3 kitchen audits completed by the RD titled Sanitation and Food Safety Checklist with a revised date of 2019, showed the RD documented the mixing bowl needed to be replaced on 3/24/21, 4/30/2, and 5/28/21. The report also indicated tiles on baseboard falling off on 4/30/21 and 5/28/21.
In an interview on 6/9/2,1 at 10:29 a.m., the RD stated her monthly kitchen inspection reports were given to the Administrator, the DS, and the Director of Nursing (DON). She stated she did not take part in the QAPI program and did not know if any kitchen projects were in QAPI. The DS stated the baseboards and mixer were reported in QAPI.
In an interview on 6/9/21, at 3:10 p.m., the Administrator (ADM) stated she kept the RD sanitation reports in a binder and usually took care of issues right away. She stated the mixer and baseboards were addressed in QAPI. ADM did not answer when she was asked why the mixing bowl was still in the kitchen if it was not useable. She stated it did not matter if it was in there because the mixer did not work. She stated in QAPI the first priority was giving the facility a face lift. She said in QAPI patient care items and infection control were next on the priority list. She did not consider the mixing bowl and the damaged baseboards a part of infection control.
In an interview on 6/9/2, at 4:15 p.m., the RD and DS stated the mixer was plugged in and did work as far as they knew.
In an interview and observation with the Administrator on 6/10/21, at 9:55 a.m., the Administrator reviewed her QAPI notes form April 21 showing sideboards were noted to be repaired by the remodeling team by July 2021. She stated sideboards meant baseboards. There was no additional information or documentation to show a plan for fixing the baseboards. The Administrator was not able to show a QAPI plan that was systematic, comprehensive, and data-driven. She stated the baseboards were not in the May 28 QAPI notes. She confirmed the RD was not a part of QAPI. She said there was no documentation

2. During a concurrent observation and interview on 6/8/21, at 12:20 p.m., with the Director of Nursing (DON), in the Medication Storage Room, an uncapped and undated multi-dose vial (MDV) of Aplisol (used in skin tests to help diagnose tuberculosis) was found in the refrigerator.
During an observation, on 6/8/21, at 12:30 p.m., with the DON, the uncapped and undated MDV of Aplisol was compared side-by-side to the capped MDV of Aplisol. The fluid level was lower in the uncapped and unlabeled MDV compared to the capped MDV, which indicated the vial had been opened.
During an interview on 6/9/21, at 4 p.m., the DON stated she cannot find a facility policy and procedure for dating opening MDV.
During a review of the Centers for Disease Control (CDC) Injection safety, dated 6/2019, it indicated If a multi-dose (vial) has been opened or accessed (e.g., needle-punctured) the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial.
Based on observations, interviews and record review the facility failed to follow it's policy and procedure for labeling and storing all drugs in a locked compartments when;
1. Multiple medications were kept on Resident 40's bedside window.
2. Multiple dose of medication vials were opened, undated and stored in medications storage room refrigerator.
These deficient practices had the potential to cause unauthorized access, medication errors and the administration of outdated medications.
Findings:
During an observation on 6/08/21, at 8:08 a.m., one tube of hydrophilic (wound dressing cream), one tube of Nystop cream and one bottle of 3 % hydrogen peroxide was stored on Resident 40's bedside window.
During an interview on 6/8/21, at 8:08 a.m., Resident 40 stated the medications were kept at his bedside window because when he needed the cream and called for assistance no one showed up.
During an observation and concurrent interview on 6/08/21, at 8:20 a.m., Licensed Vocational Nurse (LVN1) stated the medications at Resident 40's bed side are for wound care and should be stored in the treatment carts.
During a review of the facility's policy and procedures, titled Storage of Medications, revised 4/2007, it indicated Drugs shall be stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Each resident's medication shall be assigned to an individual cubicle, drawer. or cart holding area to prevent the possibility of mixing medications of several residents.

Based on interviews and record review the facility failed to ensure one (Resident 3) of six sampled residents received treatement to prevent further decline of range of motion when restorative nursing exercise was not provided as ordered by the physician.
This deficient practice had the potential for Resident 3's range of motion to further decline.
Findings:
During a review of the Minimal Data Set (MDS-an assessment screening tool used to guide care), dated 5/28/21, indicated: Resident 3 had functional limited range of motion on one side of the upper and lower extremities. Resident 3 required 2-person physical assistance with movement to and from lying positron, turns side-to-side, movement to or from bed, chair and wheelchair. Resident 3's diagnosis included hemiplegia (paralysis of one side of the body).
During a review of Resident 3's physician orders dated 11/27/20, it indicated Resident 3 was prescribed restorative nursing exercise three times a week for twelve weeks for upper/lower extremities, range of motion for contractor management.
During a review of Resident 3's care plan initiated on 1/22/21, it indicated Resident 3 was ordered restorative nursing services three times a week for 12 weeks.
During an interview with Restorative Nursing Assistant (RNA) on 6/08/21, at 11:15 a.m., RNA stated Resident 3 had not received restorative exercises for over a month because he had refused. RNA stated he did not document Resident 3's refusal anywhere.
During an interview with DON on 6/08/21, at 12:14 p.m., DON stated physical therapy evaluation (PT) was scheduled but was declined due to payment status. DON could not provide documentation to support Resident 3's refusal and scheduled PT that was declined.
The facility's policy and procedures, titled Restorative Nursing Services, revised 7/2017 indicated; Residents will receive restorative nursing care as needed to help promote optimal safety and independence.

Based on interview and record review the facility failed to provide necessary treatment and services to promote healing and prevent infection for one (Resident 51) of six sample residents when the facility staff did not provide the wound treatment on multiple shifts for Resident 51's multiple wounds.
This deficient practice could result in worsening of Resident 51's existing pressure ulcers.
Findings:
Review of the facility admission Record, dated 5/17/21, indicated Resident 51 was admitted to the facility with multiple diagnosis including sepsis (a serious condition resulting from the presence of harmful microorganisms in the blood or other tissues and the body ' s response to their presence, potentially leading to the malfunctioning of various organs, shock, and death).
During a review of the Treatment Administration Record from 5/1/21 through 5/31/21 the following treatment were not provided:
a. The treatment to the wound on the coccyx area to apply collagen powder and cover with foam dressing was not provided on 5/22/21 during the day shift
b. The treatment to the wound on the left knee to apply triad and to cover with foam dressing was not provided on 5/18/21, 5/20, 5/24, 5/26, 5/28 and 5/30/21.
c. The treatment to the wound on the left ischium (part of the hip bone) to apply santyl (an ointment to remove dead tissue from the wound) and cover with calcium alginate (a type of dressing) and foam dressing was not provided on 5/22/21 and 5/25/21.
d. The treatment to the wound on the left foot to apply wound gel and to cover with foam dressing was not provided on 5/22/21 and 5/25/21.
e. The treatment to the bilateral heels to apply A&D ointment was not provided on the evening shift of 5/31/21 and on the night shift on 5/25/21, 5/26, 5/27, 5/28, 5/29, 5/30 and 5/31/21
f. The treatment to the coccyx/buttocks area to apply moisture barrier cream was not provided on the evening shift of 5/31/21 and on the night shift on 5/25/21, 5/26, 5/27, 5/28, 5/29, 5/30 and 5/31/21
During a review of the Treatment Administration Record from 6/1/21 through 6/30/21 the following treatment were not provided:
a. The treatment to the bilateral heels to apply A&D ointment was not provided on the evening shift of 6/1/21, 6/6 and 6/7/21 and on the night shift on 6/1/21, 6/2, 6/3, 6/4, 6/6, 6/7 and 6/8/21
b. The treatment to the coccyx/buttocks area to apply moisture barrier cream was not provided on the evening shift of 6/1/21, 6/6 and 6/7/21 and on the night shift on 6/1/21, 6/2, 6/3, 6/4, 6/6, 6/7 and 6/8/21
During an interview with the (Director of Nursing) DON on 06/10/21, at 8:43 a.m., DON stated she talked to the nurses who were assigned to Resident 51's wound care and they confirmed that they did not do the wound treatments on multiple shifts for Resident 51. DON stated if staff do not provide the wound care as ordered, the wounds could get worse or Resident 51 could developed new wounds and other complications.
During an interview with Licensed Vocational Nurse (LVN) 2 on 06/10/21, at 11:29 a.m., LVN 2 stated Resident 51 refused to have the treatment on those shifts that she was assigned to did the wound care LVN 2 stated she forgot to documented Resident 51 refused treatments. LVN2 stated she did not report to anyone that Resident 51 had refused treatment. LVN 2 was not able to show any documents that Resident 51 refused the treatments on those shifts.
During a review of the facility's policy and procedure Wound Care revised October 2010 indicated . Documentation . The following information should be recorded in the resident's medical record . 9. If the resident refused the treatment and the reasons why . reporting 1. Notify the supervisor if the resident refuses the wound care .

Based on observation, interviews and record review, the facility failed to follow its Grievances/Complaint policy and procedure to make prompt efforts to resolve a complaint for one (Resident 40) of 15 sampled residents when the facility did not follow up and resolve Resident 40's concerns regarding cold food.
This deficient practice had the potential to cause emotional distress.
Findings:
During an observation on 6/08/21, at 8:08 a.m., breakfast tray for Resident 40 was on the bedside table containing eggs, waffles and harsh browns.
During an interview on 6/8/21, at 8:08 a.m., Resident 40 stated that breakfast was always cold. Resident 40 stated the harsh browns was very hard, dry and cold. Resident 40 stated he had complained to the staff about the cold food ,but it continued to be served cold.
During an interview with Dietary Supervisor (DS) on 6/09/21, at 2:38 p.m., DS stated Resident 40 had concerns about cold food. DS stated Resident 40 complained to her about cold food and she warmed his food as needed. DS stated she had no documentation regarding resident concerns and could not provide her follow up documentation.
During an interview with the Administrator (Admin) on 6/10/21, at 8:57 a.m., Admin stated she was not aware of Resident 40's concerns regarding cold food. Admin stated a grievance /concerns form must be completed to allow follow up with concerns.
The facility's policy and procedures titled, Grievance/Complaint, dated 9/1/2008 indicated; Purpose is to facilitate prompt resolution of complaints or grievances for residents and /or their representative.

Based on observation, interview and record review, the facility failed to ensure one (Resident 6) of two sampled residents needs were accommodated when administrator (Adm) told him he was not allowed to smoke.
This failure caused Resident 6 psychological distress.
Findings:
During a concurrent observation and interviews on 6/8/21, at 11:36 a.m., with Resident 44 and Resident 6 were on the back patio, Resident 44 was seen smoking and Resident 6 was not. Resident 44 stated he often assists Resident 6 to smoke, but the Adm told Resident 6 he was not allowed to smoke. Resident 6 stated the Adm told him recently he was not allowed to smoke even though he has been smoking at the facility with assistance. Resident 6 further stated he had not smoked all day and felt stressed out that he was not allowed to smoke any longer.
During an interview on 6/8/21, at 11:59 a.m., with Adm, Adm stated Resident 6 does not qualify to smoke. Adm further stated Minimum Data Set (MDS - a screening and assessment tool of health status) coordinator completed a safe smoking assessment on Resident 6 and added to the care plan.
During a concurrent interview and record review, on 6/8/21, at 12:45 p.m., with MDS, Resident 6's Smoking - Safety Screen (SSS), dated 4/22/21 was reviewed. MDS read from the SSS which indicated, Resident 6 requires one-on-one assistance from staff to smoke, and, safe to smoke with one-on-one assistance.
During a review of Resident 6's Care Plan, dated 6/7/21, the Care Plan indicated, Resident 6 is a smoker and requires one-on-one assistance with smoking.
During a review of the facility's policy and procedure (P&P) titled, Smoking Policy - Residents, dated 7/2017, the P&P indicated, Any smoking-related privileges, restrictions, and concerns (for example, need for close monitoring) shall be noted on the care plan, and all personnel caring for the resident shall be alerted to these issues.

Based on the observation, interview and record review the facility failed to provide a homelike environment when three (Resident 36, 51 and Resident 255) of five sample residents were complaining about the noise level at night.
This failure had the potential to result in Resident 36 and 255 inability to sleep and feeling tired.
Findings:
During an observation on 06/07/21, at 9:40 a.m.,. a beeping noise was heard from the call light of Resident 51's room number and was ongoing until 3:30 p.m. same day.
During an interview with the Director of Nursing ( DON) on 06/07/21, at 3:20 p.m., DON stated the call light had been broken since 6/6/21 on the night shift. DON stated they had called the company to fix the call light on 6/7/21.
During an interview with Resident 35 on 06/07/21, at 10:32 a.m., Resident 35 stated There was so much noise at night. Resident 35 stated she was not able to sleep because of a beeping noise and residents yelling.
During an interview with Resident 255 on 06/07/21, at 11:28 a.m., Resident 255 stated She was not able to sleep at nighttime because the place was so noisy. Resident 255 stated she was able to hear other residents yelling and talking load and the beeping noise.
During a review of the facility's policy and procedure Quality of Life . revised 5/2017, it indicated . 2. The facility staff and management shall maximize, to the extent possible . i. Comfortable noise level .