Pacific Gardens Nursing And Rehabilitation Center

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow the policy and procedure (P&P) titled, Admission, Transfer, Discharge and Bed-Holds, for one of three sampled residents (Resident 1) when Resident 1 (a veteran - someone who has served in a nation's armed forces) was denied admission for rehabilitation services based on payment source. This failure had the potential to delay recovery for Resident 1 following an Esophagogastroduodenoscopy (EGD - a medical procedure used to examine the lining of the esophagus, stomach, and the first part of the small intestine), Robotic Ivor [NAME] Esophagectomy (a minimally invasive surgical procedure with the use of a surgical robot to remove a portion of the esophagus to treat cancer) and Exploratory Laparotomy (a surgical procedure involving a large incision in the abdomen to visually examine the abdominal organs to identify the cause of unexplained symptoms or injuries).During an interview on 8/26/25 at 11:01 a.m. with [Hospital A] Social Worker (SW), the SW stated Resident 1 was referred to the facility on 8/5/25 for rehabilitation services for 20 days. The SW stated on 8/5/25 he spoke with the facility's Business Office Manager (BOM) and the BOM informed him the facility was unable to admit Resident 1 because [Hospital A] did not bill Medicare (the federal health insurance program for U.S. citizens and permanent legal residents, age [AGE] and older, people with disabilities and End-Stage Renal Disease (a severe condition where the kidneys have permanently lost most of their function) for the required three midnight stay (a Medicare Part A regulation requiring a patient to have a minimum of three consecutive nights of inpatient hospital care before they are eligible for covered services). The SW stated [Hospital A] billed VA (United States Department of Veterans Affairs - a cabinet-level agency of the U.S. government responsible for providing comprehensive benefits, healthcare, and support services to military veterans and their families) directly for services, not Medicare. During a review of Resident 1's [Hospital A] Demographic (HD), undated, the HD indicated, [name of Resident 1]. POS (Period of Service): Vietnam ERA. admitted : 7/11/25. discharged : 8/6/25. Health Insurance Information: Medicare Part A Effective 2/1/13. Medicare Part B Effective 2/1/13. Tricare (the U.S. military's health insurance plan providing coverage to service members, retirees, and their families) Effective 1/1/25.During a review of Resident 1's [Hospital A] Discharge Summary (DS), dated 8/6/25, the DS indicated, THORACIC SURGERY (surgical procedures performed on the organs and structures within the chest cavity). DISCHARGE SUMMARY. DATE OF OPERATION: 7/11/25. PREOPERATIVE DIAGNOSIS: Esophageal cancer (a disease in which malignant cells form in the tissues lining the hollow muscular tube that transports food and liquids from the throat to the stomach). PROCEDURES PERFORMED: 1. EGD 2. Robotic Ivor [NAME] esophagectomy. 3. Exploratory laparotomy. Diagnoses/Active Problems Managed this Hospitalization: . (Resident 1) treated with the above procedure, which the patient tolerated well. He continued to do well and on POD#20 (post-operative day 20), he was transferred to the floor. Inpatient rehab recommendations are for SNF (skilled nursing facility - a place that offers medical and therapeutic services that can only be performed safely and effectively by or under the supervision of licensed, trained health professionals to address complex medical needs and facilitate recovery after an illness, injury, or surgery). A suitable facility has been found, all necessary arrangements have been made, and the patient will be discharged .During an interview on 8/27/25 at 9:28 a.m. with the admission Services Manager (ASM), the ASM stated when the facility received a referral for admission, the admission staff reviewed the referral to ensure the facility could provide the services required. The ASM stated the admission staff would verify the residents' primary insurance, secondary insurance and copay. The ASM stated a three midnight stay at a general acute care hospital with an inpatient status was required for Medicare to cover skilled nursing services (medical and therapeutic services that can only be performed safely and effectively by or under the supervision of licensed, trained health professionals to address complex medical needs and facilitate recovery after an illness, injury, or surgery). The ASM stated Medicare would not cover skilled nursing services if there was no record of the three midnight stay at a general acute care hospital. During an interview on 8/27/25 at 9:45 a.m. with the BOM, the BOM stated when the facility received a referral for admission, the referral was reviewed to verify payment source. If a resident had no payment source, the resident was given a private option to pay. The BOM stated the admission staff would interview the resident or the resident's family member to agree on a payment plan. The BOM stated she spoke to the SW on 8/5/25 regarding the referral. The BOM stated she explained the three midnight stay qualifying requirement for Medicare coverage to the SW. The BOM stated since [Hospital A] did not bill Medicare for the three midnight stay requirement, Medicare will not cover services provided at the facility. The BOM stated she requested Resident 1's admission classification (status) to support services provided at [Hospital A] but the SW did not provide the information, therefore, the facility was unable to admit Resident 1. During a concurrent interview and record review on 8/27/25 at 10:45 a.m. with the BOM, the facility's P&P titled, Admission, Transfer, Discharge and Bed-Holds, dated 2016 was reviewed. The P&P indicated, . The facility provides equal access to quality care and opportunity for admission and does not limit, transfer or discharge prospective or current residents based upon race, creed, national origin, sex, religion, handicap, ancestry, marital or veteran status, sexual orientation or payment source. The BOM stated admission was not based on payment source. The BOM stated the facility should have offered Resident 1 with a letter of agreement (LOA - a legally binding admission contract that outlines the terms of residency, services, and financial obligations). The BOM stated she should have followed through with the SW and Resident 1 should have been admitted . During an interview on 8/27/25 at 11:10 a.m. with the Director of Nursing (DON), the DON stated during the referral process, admission staff would consult with nursing staff to ensure the facility could provide the clinical service the resident required. The DON stated the facility could not deny admission based on the payment source. The DON stated Resident 1 should have been admitted .During an interview on 8/27/25 at 11:15 a.m. with the Administrator (ADM), the ADM stated the facility should admit the resident if the facility could provide the services the resident required. The ADM stated there was a missed opportunity to admit Resident 1 due to miscommunication between the BOM and the SW. The ADM stated the BOM did not know the referral was made from a VA general acute care hospital. The ADM stated the BOM should have clarified the required information with the SW. The ADM stated the facility should have admitted Resident 1 based on a LOA. The ADM stated admission was not based on the payment source. During a review of the facility's P&P titled, Admission, Transfer, Discharge and Bed-Holds, dated 2016, the P&P indicated, Purpose: To provide uniform guidelines for admission, transfer, discharge and bed-holds in compliance with state and federal guidelines. To promote equal access to quality care and facilitate continuity with care transitions. Policy: The facility provides equal access to quality care and opportunity for admission and does not limit, transfer or discharge prospective or current residents based upon race, creed, national origin, sex, religion, handicap, ancestry, marital or veteran status, sexual orientation or payment source. admission: .The facility does not request or require residents or potential residents to waive their rights to Medicare or Medicaid (a joint federal and state health insurance program that provides free or low-cost health coverage to low-income U.S. citizens and permanent legal residents), nor does it request or require oral or written assurance that residents or potential residents are not eligible for, or will not apply for Medicare or Medicaid benefits. The facility does not request or require a third party guarantee of payment to the facility as a condition of admission or expedited admission, or continued stay in the facility; however, the facility does require a resident representative who has legal access to the resident's income or available resources to sign a contract of assurance (without incurring personal financial liability), for payment from the resident's income or resources.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to inform and provide written information on how to formulate an advance directive (a legal document that outlines a person's wishes regarding their medical care in the event they become unable to make decisions for themselves due to illness or injury) for four of 163 residents (Resident 12, Resident 30, Resident 57 and Resident 306) when the facility did not document information on how to obtain an advance directive in residents charts.
This failure violated the rights of Resident 12, Resident 30, Resident 57 and Resident 306, which could have potentially prevented these residents' wishes from being followed if they were unable to make decisions.
Findings:
During an interview on 2/3/25 at 8:55 a.m. with Resident 30 in Resident 30's room, Resident 30 stated she did not have an advanced directive and the facility did not speak to her about formulating one.
During a review of Resident30's admission Record (AR-a document with personal identifiable and medical information), dated 2/6/25, the AR indicated, Resident 12 was admitted to the facility on [DATE] with diagnoses which included hypertension (high blood pressure), protein caloric malnutrition ( PCM- is the state of inadequate intake of food, depression (a mental health condition characterized by persistent low mood, loss of interest or pleasure in activities, and other symptoms that interfere with daily functioning), constipation, trigeminal neuralgia (a chronic nerve disorder that causes severe, sudden, and excruciating pain in the face), anemia (a condition in which the body does not have enough red blood cells).
During a review of Resident 30's Minimum Data Set (MDS-a functional and cognitive abilities assessment) assessment, dated 11/12/24, the MDS assessment indicated the Brief Interview for Mental Status (BIMS) score was 15 out of 15 (a BIMS score of 13-15 indicates cognitively intact (having clear thinking, learning, and memory, which allows someone to perform daily tasks. ), 8-12 indicates moderately impaired and 0-7 indicates severe impairment), which indicated Resident 30 was cognitively intact.
During a review of Resident 30's Advanced Directives (AD), dated undated the AD indicated, no advance directives. There was no documented information on how to obtain an advance directive in resident 30's charts.
During an interview on 2/3/25 at 1:01 p.m. with Resident 12, Resident 12 stated she did not have an advance directive and was not aware the facility offered to formulate an advance directive.
During a record review of Resident 12 's AR, dated 2/6/25, the AR indicated, Resident 12 was admitted to the facility on [DATE] with diagnoses which included hypotension (low blood pressure), atrial fibrillation (a common heart rhythm disorder where the upper chambers of the heart beat irregularly and rapidly), schizophrenia (a chronic mental illness characterized by disruptions in thought processes, perceptions, emotions, and social interactions), depression (a common mental health condition characterized by persistent low mood, loss of interest or pleasure in activities, and other symptoms that interfere with daily functioning), and anxiety.
During a review of Resident 12's MDS assessment, dated 1/10/25, the MDS indicated the Brief Interview for Mental Status (BIMS) score was 14 out of 15.
During a review of Resident 12's AD, undated, the AD indicated, no advance directives. There was no document information on how to obtain an advance directive in Resident 12's charts.
During an interview on 2/5/25 at 9:50 a.m. with Resident 57 in Resident 57's room, Resident 57 stated he provided a copy of his advance directives to the facility. Resident 57 stated the facility should have a copy in his medical record.
During a review of Resident 57 's AR , dated 2/6/25, the AR indicated, Resident 57 was admitted to the facility on [DATE] with diagnoses which included diabetes mellitus type II (DM- a chronic condition where the body does not use insulin ([ a hormone produced by the pancreas that plays a crucial role in regulating blood sugar level] effectively or does not produce enough insulin to regulate blood sugar levels), hypertension (HTN-high blood pressure), anemia (condition in which the body does not have enough red blood cells (RBCs) or hemoglobin (an iron-containing protein found in red blood cells that is responsible for transporting oxygen throughout the body), constipation, spinal stenosis (a condition where the spaces in the spine narrow, putting pressure on the spinal cord and nerve roots) and gastric ulcer (a sore that develops on the lining of the stomach).
During a review of Resident 57's MDS assessment, dated 10/31/24, the MDS assessment indicated the BIMS score was 13 out of 15.
During a review of Resident 57's AD, undated, the AD indicated, No advance directives. There was no document in Resident57's medical record and no information regarding an advance directive.
During an interview on 2/05/25 at 10:11 a.m. with License Vocation Nurse (LVN) 3, LVN 3 stated, he did not remember asking residents if they would like assistance with formulation an advance directive. LVN 3 stated an advance directive was a legal documentation that required a paralegal (a legal professional who performs legal tasks under the supervision of a lawyer) and he would have to refer them to the social services director (SSD). LVN 3 stated, an advance directive was important to honor the wishes of the residents. LVN 3 stated, residents without an advance directive would have been considered full code. LVN 3 stated there were no documentation for Resident 12, 30 and 57 about the facility discussing about formulating an advance directive or if it was offered to residents.
During an interview on 2/5/25 at 10:19 a.m. with the Social Services Director (SSD), the SSD stated the admission Coordinators (AC) were responsible to speak to residents or family members about formulating an advance directive. The SSD stated residents without an advance directive were referred to the Ombudsmen (define) to help assist with formulating an advance directive. The SSD stated Residents 12, 30, and 57 were not offered advance directive assistance. The SSD stated there was no documentation on record to state the facility offered to help with obtaining an advance directive. The SSD stated it was important to have an advance directive in case of an emergency, the facility would have to make medical decisions based on the residents wishes. The SSD stated without an advance directive, the resident's wishes would not be honored. The SSD stated, We do not have anything in our documentation to state we offered the resident help to formulate one for the resident.
During an interview on 10/5/25 at 10:32 a.m. with AC 2, AC2 stated she discussed advance directives during admission. AC 2 stated residents and their family member were asked if they had an advance directive. AC 2 stated she never did not document in the resident's chart about the discussion of the advance directives. The AC 2 stated it was important to have an advance directive in case of emergency Residents wishes were honored.
During an interview on 2/07/25 at 6:43 p.m. with the Director of Nursing (DON), the DON stated, the facility should have discussed advance directives with residents and family members during admission. The DON stated the social services department should have helped residents with formulating an advance directive. The DON stated it was important to keep the wishes of the residents. The DON stated residents without an advance directive could have been do not resuscitate (DNR- also known as Do Not Attempt Resuscitation (DNAR), Do Not Attempt Cardiopulmonary Resuscitation (DNACPR), no code and sent to the hospital. The DON stated an advance directive in place ensured residents wishes were followed.
During a review of the facility's policy and procedure (P&P) titled, Advance Directives, dated 11/2017, the P&P indicated, The Patient Self-Determine Act of 1990 requires all skilled nursing facilities to inform new residents of their right to establish an advance directive .The facility has the resident or responsible party sign a form that acknowledges they have received this information and whether or not an advance directive already exist or if the resident would like to established one .Not an advance directive .POLST .
During a review of Resident 306's AR, dated 2/6/25, the AR indicated Resident 306 was admitted to the facility from the acute care hospital on 1/19/25 with diagnoses of MRSA (Methicillin Resistant Staphylococcus Aureus - a bacteria that does not get better with the type of antibiotics [a medication that inhibits or destroys infections caused by bacteria] that usually cure staph infections), Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), and depression (a mental health disorder characterized by persistently depressed mood or loss of interest in activities).
During a review of Resident 306's MDS, dated 1/28/25, the MDS section C indicated Resident 306 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive understanding on a scale of 1-15 ) score of 15 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which indicated Resident 306 was cognitively intact.
During a concurrent interview and record review on 2/06/25 at 2:10 p.m. with AC 2, Resident 306's Electronic Medical Record (EMR), undated was reviewed. AC 2 stated Resident 306 did not have an advanced directive on file. AC 2 stated when residents were admitted , staff asked the resident or called the resident's responsible party (RP) to discuss an advanced directive. AC 2 stated she would verify the resident's information before they were brought to the facility and asked if the resident had an advanced directive. AC 2 stated the SSD would follow up with the resident or RP regarding advanced directives.
During an interview on 2/06/25 at 2:23 p.m. with the Social Service Director Assistant (SSDA), the SSDA stated she was a discharge planner and did not do advanced directives for residents. The SSDA stated the SSD would discuss advanced directives with the residents.
During an interview on 2/06/25 at 2:51 p.m. with the Assistant Director of Nursing (ADON), the ADON stated the admissions nurse, nursing supervisor, and SSD were responsible for residents advance directives. The ADON stated staff tried to prioritize getting the advance directives on admission. The ADON stated if there were any changes in the resident's medical condition, staff needed to respect and honor the wishes of the resident's advance directives. The ADON stated her expectations was all residents should have a discussion on advance directives.
During an interview on 2/06/25 at 3:11 p.m. with the SSD, the SSD stated residents do not get referred to her unless they want an advanced directive. The SSD stated advanced directives for the residents were discussed with the family, nurse or admissions department. The SSD stated there was no documentation by the facility regarding discussion with residents about advanced directives in the computer. The SSD stated if the residents did not have advanced directives, there was no documentation if it was offered or discussed with resident or RP.
During a review of the facility's job description document titled, Director, Social Services, dated 11/13/17, the document indicated, . manages department to assure assessments, discharges and psychological [relating to the mental and emotional state of a person] needs of residents are met . orient resident to long term care environment and facilitate adjust upon placement . organize family groups to promote communication, education between family, resident and facility staff . assist in the education of community regarding aging, rights of residents and facility services .
During a review of the facility P&P titled, Resident Rights, dated 10/2022, the P&P indicated, . the facility will inform Resident both orally and in writing . of his or her rights . the right to request, refuse, and/or discontinue treatment . to formulate an advance directive .
During a review of the facility P&P titled, Promoting the Right of Self-Determination for Healthcare Decisions and Advanced Healthcare Directives, dated Nov/2016, the P&PN indicated . each resident will receive the necessary care and services to attain or maintain the highest practice physical, mental, and psychosocial wellbeing, in accordance with comprehensive assessments and plan of care. Each resident and/or legal healthcare decision maker will be provided a mechanism for reaching decisions concerning preferred intensity of care, including the right to forego or withdraw life sustaining treatment. Residents will be informed upon admission, and periodically, of their rights concerning self-determination of preferred intensity of care and the process for creating and implementing advanced healthcare directives .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. During a concurrent observation and interview on 2/03/25 at 8:32 a.m. with Resident 305, in Resident 305's room, Resident 305 was observed wearing a gown, in bed with head of bed elevated, eating breakfast. Resident 305 stated he had been at the facility for four days for a left below the knee amputation (BKA - surgical removal of the leg below the knee). Resident 305 stated he was not happy with his room. Resident 305 stated the white board in his room was blank, missing the date, nurse's name and nursing assistant's name. Resident 305 stated he did not know what day it was. Resident 305 stated his TV did not work due to bad reception. Observed Resident 305 changing channels with no pictures coming through the TV. Resident 305 stated his bed was broken, and the bed would not move when he pressed his buttons. Resident 305 stated this was not his first time at the facility and things were always broken.
During a review of Resident 305's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 2/6/25, the AR indicated Resident 305 was admitted to the facility from the acute care hospital on [DATE], with a readmission on [DATE]. Resident 305's diagnoses consisted of aftercare following surgical amputation, acquired absence of left leg below the knee, Type 2 Diabetes Mellitus (when the blood sugar levels in the body are too high), atrial fibrillation (an irregular heartbeat), peripheral vascular disease (the reduced circulation of blood to the arms or legs), and neuromuscular dysfunction of the bladder (when a person does not have bladder control because of brain, spinal cord or nerve problem).
During a review of Resident 305's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 2/6/25, the MDS section C indicated Resident 305 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive understanding on a scale of 1-15 ) score of 14 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which indicated Resident 305 was cognitively intact.
During an interview on 2/03/25 at 8:51 a.m. with Certified Nursing Assistant (CNA) 13, CNA 13 stated Resident 305 had a broken bed. CNA 13 stated Resident 305's bed did not go up or down or lift the head or legs. CNA 13 stated Resident 305's bed was working two days ago when he took care of Resident 305. CNA 13 stated Resident 305's TV channels were also not working. CNA 13 stated maintenance needed to move the antenna into the correct position. CNA 13 stated maintenance was aware of Resident 305's broken bed and the TV not showing clear channels.
During an interview on 2/05/25 at 10:34 a.m. with the Maintenance Supervisor (MS), the MS stated the facility used the TELS System to notify his department of any issues that needed repair. The MS stated any staff could access the system for repairs. The MS stated the resident's TVs have been working on and off. The MS stated the TVs used an antenna and the facility was looking into getting the antennas replaced with wiring for cable. The MS stated residents had bed control issues when the wired plugs were caught and pulled off when the bed side table was moved. The MS reviewed the maintenance log on his phone through the TELS system and stated 1/22/25 was the most recent repair logged in for Resident 305. The MS stated Resident 305's bed was stuck in the seated position. The MS stated he was notified on 1/23/25 of the incident but had no other requests for repairs for Resident 305's bed. The MS stated residents who are bed bound with broken beds were at risk of injury. The MS stated residents should have properly working beds and TVs.
During a review of the facility's job description document titled, Supervisor, Maintenance, undated, the document indicated, . ensure timely and effective repairs to all systems, and equipment as required . ensure that all patient and resident rooms are properly maintained (furniture, wall covering, flooring, plumbing, lights, etc.) .
During a review of the facility's policy and procedure (P&P) titled, Safe, Clean, Comfortable, and Homelike Environment, dated 6/2023, the P&P indicated, . in accordance with residents' rights, the facility will strive to provide a safe, clean, comfortable and homelike environment . that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk . refers to any environment in the facility that is frequented by residents, including (but not limited to) the residents' rooms . a determination of homelike should include the resident's opinion of the living environment . housekeeping and maintenance services will be provided as necessary . promptly reporting issues to maintenance department, such as . furniture or other bedside equipment in disrepair . broken or malfunctioning electrical equipment broken or unsafe facility equipment . ED, DON, and/or Maintenance/Housekeeping Supervisor should conduct regular facility rounds and provide general monitoring/oversight of efforts to maintain a safe, clean, comfortable environment .
During a review of the facility's Maintenance Manual P&P titled, Scope of Services, dated 8/2014, the P&P indicated, . the Maintenance Department is responsible for the condition and function of the facility's physical plant, including all utilities, grounds, and equipment . all areas of the facility and equipment therein, are inspected and maintained in accordance with the TELS Preventive Maintenance Program .
Based on observation, interview, and record review, the facility failed to maintain a safe, clean, comfortable, and homelike environment for:
1. Two of 156 residents (Resident 34 and Resident 57) when Resident 34 and Resident 57 were cold at night and staff did not ensure the temperature range was between 71-81-degree Fahrenheit (a measurement of temperature on a standard in which 32° is the temperature at which water freezes and 212° that at which it boils)
This failure resulted in an uncomfortable homelike environment for Resident 34 and Resident 57, which had the potential risk for causing hypothermia (a medical emergency that occurs when your body loses heat faster than it can produce heat) in an already vulnerable population due to their decreased ability to regulate heat.
2. When Resident 42's wall was observed with one large hole and one small hole with exposed insulation and wiring on the wall behind the bed.
This failure had the potential to result in exposure to environmental hazards including the potential for contamination or infiltration by pollutants, affecting the safety and environmental standards required for compliance.
3. Resident 305's television (TV) did not receive clear channels and Resident 305's bed was broken and would not go up or down.
These failures resulted in Resident 305 to not have a comfortable homelike environment and put resident 305 at risk of harm from a malfunctioning bed.
Findings:
1. During an observation and interview on 2/3/25 at 11:17 a.m. in Resident 34's room, Resident 34 had a sheet and 2 blankets on his bed. Resident 34 stated, The room is cold at night, and we are freezing. Resident 34 stated, I spoke to everyone, it's been ongoing for three months and it's still cold. Resident 34 stated he woke up at night from it being too cold.
During a review of Resident 34 's admission Record (AR-a document with personal identifiable and medical information), dated 2/6/25, the AR indicated, Resident 34 was admitted to the facility on [DATE] with diagnoses which included pneumonia (inflammation (a localized physical condition in which part of the body becomes reddened, swollen, hot, and often painful, especially as a reaction to injury or infection) and fluid in the lungs caused by a bacterial, viral or fungal infection), myasthenia gravis (chronic neuromuscular disease that causes weakness in the voluntary muscles), chronic obstruction pulmonary disease (COPD- group of lung diseases that cause airflow obstruction and breathing problems), pleural effusion (condition where excess fluid accumulates in the pleural space, the area between the lungs and the chest wall), pain.
During a review of Resident 34's Minimum Data Set (MDS-a functional and cognitive abilities assessment) assessment, dated 1/6/2 4 indicated the Brief Interview for Mental Status (BIMS) score was 15 out of 15 (a BIMS score of 13-15 indicates cognitively intact (having clear thinking, learning, and memory, which allows someone to perform daily tasks. ), 8-12 indicates moderately impaired and 0-7 indicates severe impairment), which indicated Resident 34 was cognitively intact .
During a review of Resident 57 's AR , dated 2/6/25, the AR indicated, Resident 57 was admitted to the facility on [DATE] with diagnoses which included diabetes mellitus type II (DM- a chronic condition where the body does not use insulin(s a hormone produced by the pancreas that plays a crucial role in regulating blood sugar level) effectively or does not produce enough insulin to regulate blood sugar levels), hypertension (HTN-high blood pressure), anemia (condition in which the body does not have enough red blood cells (RBCs) or hemoglobin (an iron-containing protein found in red blood cells that is responsible for transporting oxygen throughout the body), constipation, spinal stenosis (a condition where the spaces in the spine narrow, putting pressure on the spinal cord and nerve roots) and gastric ulcer (a sore that develops on the lining of the stomach).
During a review of Resident 57's MDS assessment, dated 10/31/24, the MDS assessment indicated the BIMS score was 13 out of 15 .
During an observation and interview on 2/3/25 at 11:35 a.m. in Resident 57's room, Resident 57 had 2 blankets on his bed. Resident 57 stated the room was cold at night and needed extra blankets. Resident 57 stated he complained to the staffs about the cold room at night. Resident 57 stated the facility gave extra blankets and he was still cold.
During an interview on 2/5/25 at 4:21 p.m. with Certified Nursing Assistant (CNA) 6, CNA 6 stated Resident 57 complained the room was cold one week ago. CNA 6 stated he entered an order into Direct Supply TELS(TELS- a building management platform and service provided by Direct Supply, primarily designed for senior living facilities, that helps manage maintenance tasks, track compliance, optimize equipment performance, and streamline operational efficiency across a building through technology and a network of service providers) and had not heard anything from the maintenance department. CNA 6 stated it was important to ensure the temperature was acceptable for resident comfort. CNA 6 stated he was aware of the Maintenance Supervisor (MS) checked the residents room temperatures during the day. CNA 6 stated he was not sure if nighttime room temperatures were comfortable for residents. CNA 6 stated it was important to maintain comfortable temperature levels for residents to rest. CNA 6 stated, To maintain the resident comfort the room should be a temperature within a certain range, if the room was too cold it can affect the quality of life for residents, and they can get sick.
During an interview on 2/5/25 at 4:40 p.m. with the MS, the MS stated he was responsible to check room temperatures. The MS stated he checked room temperatures during the daytime but not at nighttime. The MS stated room temperatures should have been between 71-81-degree Fahrenheit for comfort. The MS stated he did not check room temperatures and could not state room temperatures were within 71-81 degrees Fahrenheit. The MS stated it was important to keep residents comfortable. The MS stated he should have checked room temperatures at night. The MS stated, If my grandmother lived here and she complained I would have checked the temperature to ensure it was comfortable for her. The MS stated room temperatures should have been what residents preferred. The MS stated cold rooms did not provide a homelike environment.
During an interview on 2/6/25 at 11:23 a.m. with the Administrator (ADM), the ADM stated the MS should have checked the temperatures of the room each. The ADM stated, there should have been a temperature log every Friday entered TELS. The ADM stated room temperatures should have been between 71-81-degree Fahrenheit. The ADM stated it was important to maintain room temperature between 71-81-degree Fahrenheit for regulation and residents comfort. The ADM stated he was aware Resident 34 and Resident 57 complained about their room being cold at night. The ADM stated, staff should have checked room temperatures at night when residents complained of rooms being cold. The ADM stated room temperatures should have been checked at night to ensure it was within range. The ADM stated staff members did not check room temperatures at night. The ADM stated cold rooms were not considered a comfortable homelike environment.
During a review of the facility's policy and procedure (P&P) titled, Safe, Clean, Comfortable, and Homelike Environment, dated 6/2023, the P&P indicated, .7. The facility will strive to maintain comfortable and safe temperature level. a. Facility should strive to keep temperature in common area between 71-81 degrees Fahrenheit .
2. During an observation on 2/3/25 at 8:33 a.m., behind Resident 42's bed observed one large hole in the wall measuring about 12 inches by 8 inches, exposed insulation, two outlets with no cover that were in use with the bed plug connected to one of the outlets and a smaller second hole with exposed wiring. Photo was taken.
During an observation on 2/4/25 at 8:52 a.m., one large hole and one small hole in the wall was observed behind Resident 42's bed. The large hole remained open with exposed insulation, two outlets without a cover with the bed plugged into one of the two outlets. Small hole was observed with exposed wiring.
During an interview on 2/4/25 at 8:55 a.m. with Certified Nursing Assistant (CNA) 14, CNA 14 stated she has seen the hole in the wall behind Resident 42's bed but unknown when she first saw it. CNA 14 stated she had seen someone working on the wall a couple of weeks ago but not since then. CNA 14 stated if the holes in the wall were not fixed, it could be a hazard.
During an observation on 2/4/25 at 10:12 a.m., the larger hole in the wall behind Resident 42's bed was patched up and the smaller hole remained opened with exposed wiring. The large hole containing the two outlets, remained without an outlet cover and bed was plugged into one of the two outlets. Photo was taken.
During an interview on 2/4/25 at 10:17 a.m. with the Maintenance Assistant (MA), the MA stated when a maintenance order needed to be placed, staff would place it into online system called TELS. The MA stated there was not physical documentation for maintenance orders to be done, it is all through TELS and the Administrator (ADM) had access. The MA stated a report for the hole in Resident 42's wall was not placed into the system. The MA stated the expectation was for staff to place incidents like a hole in the wall into TELS. The MA stated if the holes were left open and someone touched the outlet, they could be electrocuted. The MA stated the exposed wires were telephone wires and those were capped off.
During an interview on 2/7/25 at 4:49 p.m. with the Maintenance Supervisor (MS), the MS stated no order was placed into TELS for the large and small holes in the wall behind Resident 42's bed. The MS stated the expectation was for staff to report any maintenance requests into TELS. The MS stated if no order was placed and the holes were to remain open, this could cause an electrocution (the injury or killing of someone by electric shock).
During an interview on 2/7/25 at 5:00 p.m. with the Director of Nursing (DON), the DON stated the expectation was staff should place a maintenance order into TELS and maintenance should be notified. The DON stated if a hole was left in the wall, it could be a hazard, and an accident could occur especially if there was wire in the wall. The DON stated even if the exposed wires were capped, you could not assume it would not cause harm.
During a review of the Job Description/ Performance Evaluation - Maintenance Supervisor, undated, the Job Description/ Performance Evaluation - Maintenance Supervisor indicated, .Ensure that all patient and resident rooms are properly maintained (furniture, wall covering, flooring, plumbing, lights, [etcetera]) .
During a review of the facility's policy and procedure (P&P) titled, Maintenance Manual Policies and Procedures, dated 8/14, the P&P indicated, .1. The Maintenance Department will maintain the facility's physical plant in accordance with the TELS schedule that will serve to provide a safe, functional and aesthetically (in a way that gives pleasure through beauty) pleasing environment .4. The facility staff shall prepare and submit a Maintenance Work Order Form for any corrective maintenance repair work identified or required .

Based on interview and record review the facility failed to provide residents and residents' responsible party (RP- a person designated to make decisions for a resident) written information regarding the bed hold policy for two of six sampled (Resident 3 and Resident 455) when:
1. No written notices about the facility's bed hold policy was provided to Resident 3 or their RP when he was transferred to the hospital on 2/2/25.
This failure violated Resident 3 and his RP's right to be notified in writing of the facility's bed hold policy.
2. Resident 455 was not provided a bed hold policy prior to being transferred out of the facility due to being a non-Medi-Cal member.
This failure had the potential to result in loss of bed availability, confusion, disputes, and quality of care concerns for Resident 455.
Findings:
1. During a concurrent interview and record review on 2/6/25 at 10:53a.m. with Licensed Vocational Nurse (LVN) 3, Resident 3's Notice of Transfer (NT),dated 2/6/25 was reviewed. The NT indicated Resident 3 was transferred to the hospital on 2/2/25. LVN 3 stated nursing staff called Resident 3's RP to notify them of the bed hold information and gave Resident 3 the NT form but not the bed hold policy. LVN 3 stated he was not aware residents, or their representatives needed to be provided with the bed hold policy upon transfer to the hospital.
During an interview on 2/7/25 at 2:28 p.m. with LVN 6, LVN 6 stated nurses called Resident 3's RP about information regarding the bed hold, but did not give the resident or their RP the facility's bed hold policy. LVN 6 stated giving Resident 3's RP the bed hold policy would allow them to better understand the policy and read it on their own time.
During an interview on 2/7/25 at 3:01 p.m. with Admissions Coordinator (AC) 1, AC1 stated Resident 3 was notified of the facility's bed hold policy upon admission and when he was sent out to the hospital his nurse called his RP to let them know of the bed hold policy as well. AC 1 stated the admissions office called the resident or their RP in the hospital to remind them of the bed hold policy, but the phone call was not documented anywhere. The admissions office staff or nursing staff did not give Resident 3 notice of the bed hold policy prior to his transfer to the hospital.
During an interview on 2/7/25 at 3:43 a.m. with the Director of Nursing (DON), the DON stated, Resident 3 was not notified of the facility's bed hold policy upon his transfer to the hospital. The DON stated it was important to provide residents the bed hold policy during transfers to the hospital because it helped ensure residents or their RPs could understand the bed hold policy and were able to ask questions if needed.
During a review of the facility's Policy and Procedure (P&P) titled, Admission, Transfer, Discharge, and Bed Holds, dated 12/16, the P&P indicated, . The facility will notify the resident or resident representative at the time admission and again prior to hospital transfer or therapeutic leave, of bed hold and readmission policies .
2. During an observation and interview on 2/4/25 at 4:00 p.m. with Resident 455, Resident 455 stated when he was transferred out of the facility to the hospital, he was never provided with a bed hold policy. Resident 455 was observed looking through documents provided to him by the facility and only had documents regarding Medicare coverage. Resident 455 was unable to locate documents for a bed hold policy.
During a review of Resident 455's Minimum Data Set (MDS - a resident assessment tool), dated 1/25/25, the MDS indicated in Section C, Cognitive (thinking, reasoning or remembering) Patterns, Brief Interview for Mental Status (BIMS - an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score was a 15 out of 15 (0-7 indicated severe cognitive impairment [memory loss, poor decision making skills], 8-12 moderate cognitive impairment, 13-15 cognitively intact) indicating Resident 455 was cognitively intact.
During a review of the facility'sNT, dated 1/18/25, the NT indicated the responsible party was himself, and Resident 455 was notified of the transfer to the hospital and was aware of the clinical situation. The NT indicated Resident 455 was, .alert, oriented and follows instructions . The Form indicated a bed hold policy was not given to Resident 455 prior to hospital transfer.
During an interview on 2/4/25 at 4:25 p.m. with the Social Services Director (SSD), the SSD stated Resident 455's health insurance would not pay for the resident's bed hold and only Medi-Cal residents would have a bed hold because it was paid for. The SSD was unable to locate documentation to confirm if the bed hold policy was given to Resident 455 prior to being sent to the hospital.
During an interview on 2/5/25 at 2:57 p.m. with LVN 3, LVN 3 stated residents were not provided with a bed hold policy when they were transferred out of the facility. LVN 3 stated residents were provided with the transfer form that was filled out with the resident's information. LVN 3 stated, haven't heard of giving a resident a bed hold policy.
During an interview on 2/7/25 at 3:00 p.m. with AC 1, AC 1 stated residents would be given a bed hold policy upon admission into the facility in the admission packet. AC 1 stated a resident would not receive another bed hold policy when they were transferred out from the facility by the admission office. AC 1 stated residents with Resident 455's health insurance were not offered a bed hold upon transfer. AC 1 stated many residents do not know how the bed hold process works, and it would make sense to provide them with an additional bed hold policy upon transfer out of the facility to inform the resident of what that meant.
During an interview on 2/7/25 at 5:00 p.m. with the DON, the DON stated Resident 455's health insurance would not pay for a bed hold but residents with Resident 455's health insurance would be asked if they would like to pay out of pocket for a bed hold. The DON stated that a bed hold policy was not given to a resident prior to being transferred out of the facility.
During a review of the facility's P&P titled, Discharge/Transfer of the Resident, dated 2006, the P&P indicated, .Complete Bed hold notification form per facility procedure . The P&P did not indicate a physical copy of the bed hold policy should be provided to a resident prior to being transferred out of the facility.
During a review of the facility's P&P titled Admission, Transfer, Discharge and Bed-Holds, dated 2016, the P&P indicated, .Upon transfer or discharge, a notice of transfer and discharge, as well as the bed hold notification will be completed and given to the resident at the time of the transfer or discharge or as soon as practicable .The facility will notify the resident or resident representative at the time [of] admission and again prior to hospital transfer or therapeutic leave, of bed hold and readmission policies. The notification will include the duration of the state bed hold allowance in which the resident is permitted to return and resume residence within the facility and the reserve bed-payment requirements of the State plan . The P&P did not indicate a physical copy of the bed hold policy should be provided to a resident prior to being transferred out of the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan (CP - a detailed approach to care customized to an individual resident's needs) for 7 of 36 sampled residents (Residents 20, 26, 34, 37, 54, 86, and 409) when:
1. Resident 37 did not have a CP developed for an indwelling foley catheter (a thin, flexible tube that is inserted into your bladder to drain urine).
This failure of developing a CP for Resident 37's foley catheter had the potential to place Resident 37's safety at risk and her specific needs not being met.
2. Resident 26's CP interventions were not implemented to meet his visual needs.
This failure resulted in Resident 26 not wearing his glasses for five days which had the potential to lead to injury or decreased participation in activities of daily living (ADLs).
3. Resident 409's CP was not developed to address the use of an anticoagulant (blood thinner).
This failure had the potential for Resident 409 to experience severe bruising and bleeding which could lead to serious medical condition and hospitalization.
4. Resident 86 did not have a CP for anticoagulation (a medication that prevents blood from clotting) medication monitoring.
This failure placed Resident 86 at risk for increased bleeding and bruising.
5. Resident 34 did not have a CP for his oxygen and albuterol sulfate (medication used to treat breathing problems caused shortness of breath) nebulizer (a small machine that turns liquid medicine into a mist that can be easily inhaled) treatment.
This failure did not allow the team to collaborate and communicate Resident 34's respiratory needs and had the potential for needs to go unmet.
6. Resident 20's CP was not accurate when Resident 20 had a diagnosis of right sided weakness but the CP indicated Resident 20 had left sided weakness.
This failure resulted in Resident 20's physical needs not being met for performing range of motion (ROM-the extent or degree of movement that a joint or series of joints can achieve in a specific direction) for the right upper extremity that led to the development of a contracture (a stiffening/shortening at any joint, that reduces the joint's range of motion).
7. Resident 54 with known decline in functional status (loss of ability to perform daily activities independently), impaired safety awareness (reduced ability to recognize and respond to dangers) and the need to be supervised and assisted while transferring and ambulating (walking) was not adequately supervised when Resident 54 was in her room.
This failure resulted in Resident 54 experiencing multiple unwitnessed falls due to a lack of supervision on the following dates 01/17/25, 01/06/25, 12/23/24, 11/22/24, 09/01/24, 07/22/24, and 03/19/24.
Findings:
1. During a review of Resident 37's Face Sheet (a summary of important information regarding a patient which include patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 2/5/25, the Face Sheet indicated, Resident 37 was admitted to the facility on [DATE] with a diagnosis of cellulitis (a serious deep infection of the skin caused by bacteria) of the left lower limb, muscle weakness (loss of muscle strength), mild dementia (a brain condition that causes memory loss, thinking problems, and behavioral changes), neuromuscular dysfunction of the bladder (occurs when the nerves that control the bladder don't work properly) and peripheral vascular disease (a condition that occurs when blood vessels narrow or block, reducing blood flow to the arms and legs).
During a review of Resident 37's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive and physical function) assessment, dated 1/16/25, the MDS assessment indicated Resident 37's Brief Interview for Mental Status (BIMS -assessment of cognitive(define) status for memory and judgment) assessment score was 15 out of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 37 was cognitively intact.
During a review of Resident 37's Physician Order (PO), dated 1/31/25, the PO indicated, . Order date: 1/31/25 . Communication Method: Phone . Order Summary: Foley Catheter . Confirmed by: RN .
During a concurrent observation and interview on 2/4/25 at 9:05 a.m. with Resident 37, in Resident 37's room, Resident 37 was observed to have an indwelling foley catheter, Resident 37 stated she had the catheter for a few weeks.
During a review of Resident 37's Electronic Medical Record (EMR), on 2/4/25, the EMR indicated no CP was developed for Resident 37's foley catheter.
During an interview on 2/6/25 at 10:27 a.m. with Registered Nurse (RN) 3, RN 3 stated Resident 37 did not have a CP in place at the time of record review RN 3 stated Resident 37 should have had a CP put in place on 1/31/25 when the foley catheter order was placed and it was not. RN 3 stated CP's were important to protect Resident 37 from further complications and they direct the care for the resident on a daily basis. RN 3 stated CP's tell all staff members what they should be monitoring for the foley catheter and all staff have to follow them.
During an interview on 2/6/25 at 11:07 a.m. with the Director of Staff Development (DSD), the DSD stated the reason for Resident 37 not having a CP was a break down in communication between staff. The DSD stated staff would not know the approach on what to do for the residents catheter with no CP in place.
During an interview on 2/7/25 at 2:15 p.m. with the Infection Preventionist (IP), the IP stated Resident 37 had a change of condition and needed a foley catheter placed for a neurogenic bladder (occurs when the nerves that control the bladder do not work properly). The IP stated when a change of condition occurred, a CP should have been created and it was not. The IP stated he created a CP for Resident 37's foley catheter on 2/5/25, but Resident 37 did not have one in the EMR prior. The IP stated CP's were important for staff communication and helped notify them on how to care for the foley catheter. The IP stated due to the CP not being in the EMR, staff could have improperly handled the catheter and this could have increased the Resident 37's risk for infection and ultimately their safety. The IP stated staff did not follow the facility's policy and procedure (P&P) Care Plan, Comprehensive.
During an interview on 2/7/25 at 4:35 p.m. with the DON, the DON stated the foley catheter was placed at an outside Urology appointment in January 2025. The DON stated the foley catheter CP should have been created when Resident 37's change of condition occurred and it did not. The DON stated CP's are vital so staff knew the plan of care for the resident. The DON stated the facility did not follow the P&P, Care Plans, Comprehensive.
During a review of Resident 37's Urology Office Visit (UOV), dated 1/15/25, the UOV indicated, .Assessment: Feeling of incomplete bladder emptying . neuromuscular dysfunction of bladder . retention of urine . Plan: . catheter placed .
During a review of the facility's P&P titled, CPs, Comprehensive, dated 12/2017, the P&P indicated, .It is the policy of this facility to develop . the comprehensive resident CP. The CP is directed toward achieving and maintaining optimal status of health, functional ability and quality of life . plans are reviewed and revised by the Interdisciplinary Team . following an assessment for a significant change of condition .
During a review of Nursing World.org Professional Reference titled, The American Nurses Association- Nursing: Scope and Standards of Practice, Third Edition, dated July 2015, (found at https://www.nursingworld.org/~4af71a/globalassets/catalog/book-toc/nssp3e-sample-chapter.pdf) the reference indicated, .The Standards of Practice describe a competent level of nursing care as demonstrated by the critical thinking model known as the nursing process. The nursing process includes the components of assessment, diagnosis, outcomes identification, planning, implementation, and evaluation. Accordingly, the nursing process encompasses significant actions taken by registered nurses and forms the foundation of the nurse's decision-making . Standard 1. Assessment the registered nurse collects pertinent data and information relative to the healthcare consumer's health or the situation .
During a review of National Library of Medicine.org Professional Reference titled, Nursing Process, dated 4/10/23, (found at https://www.ncbi.nlm.nih.gov/books/NBK499937/) the reference indicated, . Planning: The planning stage is where goals and outcomes are formulated that directly impact patient care based on guidelines. These patient-specific goals and the attainment of such assist in ensuring a positive outcome. Nursing CPs are essential in this phase of goal setting. CPs provide a course of direction for personalized care tailored to an individual's unique needs. Overall condition and comorbid conditions play a role in the construction of a CP. CPs enhance communication, documentation, reimbursement, and continuity of care across the healthcare continuum . vital to positive patient outcomes . the nursing process to guide care is clinically significant going forward in this dynamic, complex world of patient care. Aging populations carry with them a multitude of health problems and inherent risks of missed opportunities to spot a life-altering condition .
2. During a review of Resident 26's admission Record (AR- document containing resident personal information), dated 2/4/25, the AR indicated, Resident 26 was admitted to the facility on [DATE], with diagnoses which included peripheral vascular disease, unspecified (reduced circulation of blood to a body part, other than the brain or heart, due to a narrowed or blocked blood vessel ) muscle weakness generalized, other reduced mobility, unspecified dementia, severe (an advanced stage of cognitive decline where significant impairment in memory, thinking, reasoning, and daily functioning occurs), with psychotic disturbance (a mental illness that causes a loss of contact with reality), and primary open-angle glaucoma, bilateral, stage unspecified (a progressive condition that can cause permanent vision loss, and even blindness).
During a review of Resident 26's MDS, dated 12/18/24, the MDS assessment indicated Resident 26's BIMS assessment score was 12 out of 15 which indicated Resident 26 had moderate cognitive deficit (a decline in thinking abilities, like memory, reasoning, and problem-solving, where someone struggles with complex tasks and may need assistance with daily activities, but can still perform basic self-care and understands most situations ). The MDS assessment indicated Resident 26's Hearing, Speech, and Vision was moderately impaired (limited vision; not able to see newspaper headlines but can identify objects). The MDS assessment indicated Resident 26 had corrective lenses.
During a review of Resident 26's Reconciliation Records Patient's Clothes and Possessions, dated 12/12/24, the Reconciliation Records Patient's Clothes and Possessions indicated Resident 26 was admitted with glasses.
During a review of Resident 26's CP, dated 12/13/24, the CP indicated, .The resident has impaired visual function [related to] Primary open angle glaucoma bilateral stage unspecified .Remind resident to wear glasses when up. Ensure resident is wearing glasses which are clean free from scratches and in good repair. Report any damage to nurse/family .Tell the resident where you are placing their items .
During a concurrent observation and interview on 2/3/25 at 10:40 a.m. with Resident 26 in Resident 26's room, Resident 26 was observed sitting in his wheelchair, between his bed and the wall, with no glasses on. Resident 26 stated, I do not see well. Resident 26 stated he had glaucoma in both eyes, and it was difficult to see the clock on the wall, read newspapers, or dial numbers on his phone. Resident 26 stated he relied on staff to set things up in front of him to perform tasks. Resident 26 stated all of his personal belongings were kept in the top drawer of his nightstand. Resident 26 stated he had not worn or seen his glasses for several days. Resident 26 stated his glasses helped him see better.
During a concurrent observation and interview on 2/3/25 at 12:17 p.m. with Resident 26 in Resident 26's room, Resident 26 was observed sitting in his wheelchair, between his bed and the wall, with no glasses on. Resident 26 stated the clock on the wall to his right was difficult to read even though it was close. Resident 26 stated he called his daughter most days at 9:00 a.m. but it had gotten harder to see the phone pad numbers. Resident 26 stated he needed assistance from staff to make calls to his daughter. Resident 26 stated when staff were busy, he had to wait for staff to be available to assist him with calling his daughter or to ask for the time.
During an interview on 2/4/25 at 4:09 p.m. with RN 2, RN 2 stated Certified Nursing Assistants (CNA), Licensed Vocational Nurses (LVN), and RN's were responsible to review and follow CPs for each resident. RN 2 stated CPs notified staff of each resident's needs and how to provide individualized care. RN 2 stated Resident 26 was admitted to the facility in December and never saw him wearing glasses. RN 2 stated Resident 26's CP should have been followed to ensure Resident 26 was wearing his glasses when up. RN 2 stated glasses helped improve vision. RN 2 stated Resident 26 was at risk for injury without his glasses. RN 2 stated Resident 26 was at risk for not participating in activities if he could not see.
During a concurrent observation and interview on 2/4/25 at 4:16 p.m. with CNA 3 in Resident 26's room, CNA 3 stated she could not locate Resident 26's glasses in his nightstand, bedside table, closet or bed. CNA 3 stated she had never seen Resident 26 with glasses on. CNA 3 stated Resident 26 was at risk for injury if he could not see an obstacle near him. CNA 3 stated Resident 26 was at risk for decreased participation in activities and eating if he could not see items in front of him. CNA 3 stated missing glasses were reported to the Social Services Director (SSD).
During an interview on 2/4/25 at 4:19 p.m. with the SSD, the SSD stated she expected staff to assist residents with their vision needs and follow care planned interventions. The SSD stated Resident 26 was admitted to the facility with glasses and no reports had been made for his missing glasses. The SSD stated she expected staff to follow assessments and interventions to assist each resident to see. The SSD stated she expected staff to notify her when Resident 26's glasses could not be located.
During an interview on 2/5/25 at 10:16 a.m. with the Customer Services/Social Services (SS), the SS stated she spoke to Resident 26's Responsible Party (RP) on 2/4/25 and the RP stated she had taken the glasses home on 1/30/25. The SS stated Resident 26 went 5 days without his glasses. The SS stated CNAs, LVNs and RNs had not implemented Resident 26's careplanned vision interventions. The SS stated if Resident 26's vision care planned interventions were implemented, it would have identified his glasses were missing 5 days ago. The SS stated Resident 26 was at risk for injury without his glasses.
During an interview on 2/6/25 at 5:02 p.m. with the DON, the DON stated she expected all staff to implement care planned interventions. The DON stated staff had not implemented Resident 26's vision care planned interventions to remind and ensure him to wear his glasses when up. The DON stated staff should have identified and reported Resident 26 did not have his glasses on 1/30/25 to the SSD. The DON stated the CP should have been updated to reflect Resident 26 no longer had glasses. The DON stated it was important each resident had a personalized and individualized CP.
During a concurrent interview and record review on 2/7/25 at 10:12 a.m. with LVN 3, Resident 26's CP, dated 12/13/25 was reviewed. The CP indicated Resident 26 required assistance and reminders to wear his glasses when up. LVN 3 stated Resident 26 should have been wearing his glasses every day when awake. LVN 3 stated all staff providing care to Resident 26 should have reviewed his CP and ensured he had his glasses on when up. LVN 3 stated staff were not implementing Resident 26's vision care planned interventions or it would have been identified he no longer had his glasses on 1/30/25.
During a review of the facility's policy and procedure (P&P) titled, Vision Services, dated 11/2017, the P&P indicated, .If residents use adaptive device, these items will be included in the resident's plan of care .
During a review of the facility's training lesson titled, ADL Care and Call Lights, undated, the ADL Care and Call Lights training lesson indicated the program was attended by all-staff. The training lesson indicated, .identify ADL needs for all residents .eyeglasses .eyewear should be clean and placed on residents daily, removing when in bed/shower and storing in proper containers .
3.During a review of Resident 409's AR, dated 2/4/25, the AR indicated, Resident 409 was admitted to the facility on [DATE], with diagnoses which included other sequelae of cerebral infarction (a medical condition where blood flow to the brain is interrupted, leading to the death of brain cells.), type 2 diabetes mellitus ( a medical condition in which the sugar level is high in the blood stream), chronic kidney disease stage 3 (a moderate level of kidney damage that reduces the kidneys' ability to filter waste from the blood), intracardiac thrombosis (a condition where a blood clot forms within the chambers of the heart), personal history of transient ischemic attack (TIA-a temporary interruption of blood flow to the brain, causing stroke-like symptoms (symptoms that mimic a stroke, but are caused by another condition. Symptoms of stroke-like conditions include sudden weakness, numbness, difficulty speaking, vision changes, or loss of balance) and cerebral infarction (a stroke that occurs when blood flow to the brain is blocked) without residual deficits (a loss of function that can occur after an injury to the brain).
During a review of Resident 409's MDS assessment, dated 2/3/25, the MDS assessment indicated Resident 409's BIMS assessment score was 15 out of 15 which indicated Resident 409 had no cognitive deficit.
During a review of Resident 409's Medication Administration Record (MAR- a standardized record that organizes essential information about a patient and their prescribed medications), dated 1/25/25, the MAR indicated, .Apixaban Oral Tablet 5 [milligrams- a unit of measurement used to measure the dosage of medication] (Apixaban [ a type of medicine known as an anticoagulant. It decreases the clotting ability of the blood and helps prevent harmful blood clots from forming]) give 1 tablet by mouth two times a day . order date 1/25/25 .[discontinued] date 2/1/25 . The MAR indicated, .Apixaban Oral Tablet 5 MG (Apixaban) Give 1 tablet by mouth two times a day .order date 2/1/25 .
During a review of Resident 409's Order Review Report, dated 2/5/25, the Order Review Report indicated, Apixaban Oral Tablet 5 MG give 1 tablet by mouth two times a day for [left ventricular- the lower left chamber of the heart] mural thrombus [a blood clot that sticks to the wall of a blood vessel or heart chamber] The Order Review Report indicated, .order status .active .
During a concurrent observation and interview on 2/4/25 at 12:21 p.m. with Resident 409 in Resident 409's room, Resident 409 was observed sitting in her wheelchair eating lunch. Resident 409 stated she was admitted to the facility following a prolonged hospitalization for a TIA. Resident 409 stated she started the anticoagulant at the hospital and had taken the anticoagulants for .at least a month . Resident 409 stated she had not received any education since admission to the facility on anticoagulant side effects or potential complications. Resident 409 stated she was not aware of any side effects or complications to monitor for.
During a concurrent interview and record review on 2/4/25 at 12:25 p.m. with RN 2, Resident 409's MAR and CP, dated 1/25/25 were reviewed. RN 2 stated Resident 409 had received Apixaban since admission. RN 2 stated Apixaban was an anticoagulant. RN 2 stated anticoagulants were a blood thinner, and Resident 409 could bruise easily and have uncontrolled bleeding if injured. RN 2 could not locate an anticoagulant CP for Resident 409. RN 2 stated Resident 409 did not have a CP to address the use of an anticoagulant and one would be created immediately for her safety. RN 2 stated a CP must be in place for all residents to address the use of an anticoagulant. RN 2 stated it was important the CP reflected the use of an anticoagulant to ensure education and monitoring were in place. RN 2 stated the purpose of the CP was to reflect each residents current conditions and alert all staff to individualized treatment, side effects, and monitoring precautions.
During an interview on 2/5/25 at 10:53 a.m. with LVN 1, LVN 1 stated all CPs were expected to be personalized and reflect Residents current conditions. LVN 1 stated all residents on anticoagulant therapy must have a CP in place. LVN 1 stated the anticoagulant CP ensured all members of the healthcare team were aware, took precaution to prevent injury, and monitored for anticoagulant side effects. LVN 1 stated common side effects were bruises, tarry stools, and uncontrolled bleeding. LVN 1 stated the CP ensured ongoing education was provided to Resident 409 to report any injuries, avoid sharp objects such as razors and any bleeding. LVN 1 stated Resident 409 was at risk for uncontrolled bleeding if side effects were not identified from the CP.
During an interview on 2/6/25 at 5:02 p.m. with the DON, the DON stated all members of the interdisciplinary team (IDT), including the resident, were responsible to participate in developing the CP. The DON stated all CPs were expected to reflect the residents needs and active orders to ensure appropriate monitoring precautions and goals were in place. The DON stated Apixaban was an anticoagulant and all anticoagulants were expected to be care planned. The DON stated it was expected Resident 409 had an anticoagulant CP to ensure she was being monitored by all members of the healthcare team. The DON stated the CP ensured continuing education was provided to the resident regarding anticoagulation therapy. The DON stated without an anticoagulant CP Resident 409 was not being monitored and was at risk for bruising and uncontrolled internal bleeding. The DON stated it was important all members of the IDT were aware Resident 409 was on an anticoagulant to accurately reflect her needs, goals, and interventions. The DON stated it was important each resident had a personalized and individualized CP. The DON stated she expected all staff to follow care planned interventions.
During a review of the facility's P&P titled, Care Plan, Comprehensive, dated 12/2017, the P&P indicated, .the CP is directed toward achieving and maintaining optimal status of health, functional ability, and quality of life . CPs should be developed by the interdisciplinary team (IDT), which includes .nursing management .Licensed Nurses and Nursing Assistants .CPs are individualized through the identification of resident concerns, unique characteristics, strengths and individual needs .CPs become a comprehensive tool for the IDT to utilize as a reference for identified concerns and approaches to establish guidance for meeting resident individual needs .Individualized CPs should be accessible to all caregivers .Problem resolution and changes in goals and approaches may be identified and initiated by any IDT member .
During a review of the facility's P&P titled, Resident Rights, dated 10/2022, the P&P indicated, .the resident has .the right to participate in the development and implementation of his or her person-centered plan of care .the right to participate in establishing the expected goals and outcomes of care, the type, amount, frequency, and duration of care, and any other factors related to the effectiveness of the plan of care .the right to be informed .of the risks and benefits of proposed care .and treatment .
During a review of the facility's job description document titled, Certified Nursing Assistant, dated 11/13/17, the document indicated, .The primary purpose of this position is to provide each of your assigned residents with routine daily nursing care and services in accordance with the residents assessment and CP, assuring resident safety .Provide Restorative assistance and support to maintain residents ADL function as per the plan of care .Provide the clinical and support services needed to meet all physical and psycho-social needs of the residents and patients .
During a review of the facility's job description document titled, LVN/LPN, dated 11/13/17, the document indicated, .Develops, implements, evaluates, and updates plans of care accordingly .Encourages Patients to participate in prescribed therapies .Reports, documents, and CPs non-compliance .participates in IDT .and reviews plan of care for assigned Patients .Identifies Patient risk(s) areas and appropriately implements preventative measures as needed .facilitates compliance with individualized CPs .Collaborates/Educates Patients .to achieve highest level of wellness in accordance with plans of care .Develops, reviews, and amends CPs accordingly .
During a review of the facility's job description document titled, Registered Nurse, dated 11/13/17, the document indicated, .Develops, implements, evaluates, and updates plans of care accordingly .Encourages Patients to participate in prescribed therapies .Reports, documents, and CPs non-compliance . participates in IDT .and reviews plan of care for assigned Patients . Identifies Patient risk(s) areas and appropriately implements preventative measures as needed . Collaborates/Educates Patients .to achieve highest level of wellness in accordance with plans of care . Develops, reviews, and amends CPs accordingly .
4. During a concurrent observation and interview on 2/03/25 at 9:51 a.m. with Resident 86 in Resident 86's room, Resident 86 was observed dressed, lying in bed, wearing a neck collar (an instrument used to support the neck and spine and limit head movement). Resident 86 stated she was admitted to the facility on [DATE], after having neck surgery. Resident 86 stated she was taking a pain medication for her neck pain and headaches. Resident denied bleeding, and no bruising was observed.
During a review of Resident 86's AR dated 2/6/25, the AR indicated Resident 86 was admitted to the facility from the acute care hospital on 1/10/25 with diagnoses of chronic obstructive pyelonephritis (scarring of the kidney due to recurrent urinary infections [a condition in which bacteria invade and grow in the urinary tract]), acute embolism and thrombosis (obstruction of an artery by a clot of blood) of the deep vein of the left lower extremity (lower leg), type 2 diabetes (when the blood sugar levels in the body are too high), fusion of the spine (a surgical procedure used to correct problems with the small bones in the spine), cervical region (neck area of the spine), atrial fibrillation (an irregular heartbeat), and anxiety disorder (a mental health disorder characterized by feelings of worry or fear that are strong enough to interfere with one's daily activities).
During a review of Resident 86's MDS, dated 1/19/25, the MDS section C indicated Resident 86 had a BIMS score of 14 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which indicated Resident 86 was cognitively intact.
During a review of Resident 86's Clinical Physician Orders, dated 2/6/25, the Clinical Physician Orders indicated, . Apixaban [a prescription anticoagulant medication that helps prevent and treat blood clots)] Oral Tablet 5 [milligrams (MG) - a unit of measurement] . Anticoagulant [medication used to stop the blood from clotting too easily] Side Effect Monitoring [every] shift: Monitor for excessive signs/symptoms of bleeding and/or bruising . Directions . every shift . Start Date . 1/11/2025 07:00 .
During a concurrent interview and record review on 2/06/25 at 9:54 a.m. with LVN 3 Resident 86's CP (CP), undated was reviewed. The CP indicated, . the resident is on anticoagulant therapy . [related to] atrial fibrillation [an irregular heartbeat] . Date Initiated: 01/11/2025 . Goal . the resident will be free from discomfort or adverse reactions related to anticoagulant use . LVN 3 stated there were no monitoring interventions for bleeding or bruising. LVN 3 stated there should have been interventions to monitor for bleeding or bruising for Resident 86's anticoagulation medication. LVN 3 stated monitoring was important due to the risk of increased bleeding for Resident 86. LVN 3 stated Resident 86 should have had an anti-coagulant CP with monitoring for bleeding and bruising.
During an interview on 2/06/25 at 2:51 p.m. with the Assistant Director of Nursing (ADON), the ADON stated the medication CP was completed by the admitting supervisor on the resident's admission to the facility. The ADON stated residents ordered anticoagulant medications should have had a CP completed by the admitting supervisor. The ADON stated her expectation was for residents on anti-coagulation medication to have a CP to monitor for bleeding and bruising.
During a review of the facility's policy and procedure (P&P) titled, Care Plan, Comprehensive, dated 12/2017, the P&P indicated, . the CP is directed toward achieving and maintaining optimal status of health . CPs are individualized . baseline CPs are initiated within 48-hours of admission and completed no later than seven (7) days after the completion of the RAI .individualized CPs should be accessible to all caregivers . CPs should be reviewed within 21 days after admission .
5. During a review of Resident 34 's AR dated 2/6/25, the AR indicated, Resident 34 was admitted to the facility on [DATE] with diagnoses which included pneumonia (inflammation (a protective response of the body to harmful stimuli, such as infections, injuries, or toxins) and fluid in your lungs caused by a bacterial, viral or fungal infection), myasthenia gravis (chronic neuromuscular disease that causes weakness in the voluntary muscles), chronic obstruction pulmonary disease (COPD- group of lung diseases that cause airflow obstruction and breathing problems), pleural effusion (condi[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to revise a comprehensive person-centered care plan for one of three sampled residents (Resident 120), when Resident 120's care plan had active treatment interventions (actions to address resident identified needs) for a stage two pressure ulcer (partial-thickness loss of skin, presenting as a shallow open sore or wound) that had already healed.
This failure had the potential for Resident 120's care to not be centered and could cause unclear communication amongst the healthcare team.
Findings:
During the review of Resident 120's admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes) dated 12/8/23, the AR indicated Resident 120 was admitted on [DATE] with the diagnoses of: hypertension (HTN-high blood pressure), obesity (excessive fat accumulation that presents a health risk), and gait abnormalities ( unusual or irregular walking pattern).
During a review of Resident 120's Minimum Data Set (MDS- resident assessment tool which indicated physical and cognitive abilities), dated 1/20/25, the MDS indicated a Brief Interview for Metal Status (BIMS- an assessment of cognitive function) score of fifteen (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment), which indicated Resident 120 had no cognitive impairment.
During an interview on 2/4/25 at 9:38 a.m. in Resident 120's room, Resident 120 stated she got blisters on her bottom from time to time. Resident 120 stated staff treated the area by applying powder and bandages.
During an interview on 2/5/25 at 9:57 a.m. with Certified Nurse Assistant (CNA 7), CNA 7 stated Resident 120 did not have a wound. CNA 7 stated that care plans guided how to care for the resident. CNA 7 stated if the care plans were not accurate, they would not know what needed to be done.
During an interview on 2/5/25 at 10:15 a.m. with CNA 8, CNA 8 stated care plans informed them on how to care for the resident. CNA 8 stated an updated care plan provided them with the necessary information for Resident 120's care.
During a concurrent interview and record review on 2/5/25 at 1:44 p.m. with License Vocational Nurse (LVN 1), Resident 120's MDS was reviewed. The MDS dated 1/20/25 indicated Resident 120's stage two left gluteal (group of muscles that make up the buttock area) pressure ulcer had healed on 1/15/25. Resident 120's care plan dated 12/2/24 was also reviewed. The care plan indicated Resident 120 had an active care plan for a stage two pressure ulcer. LVN 1 stated the care plan should have been resolved once the wound healed. LVN 1 stated it was important for care plans to be resolved so that, if the issue happened again, staff would be aware of it. LVN 1 stated if care plans were not updated, specific care for the resident could be missed.
During an interview on 2/7/25 at 8:20 a.m. with the Director of Nursing (DON). The DON stated it was important for resident care plans to be accurate, because it communicated the needs of the resident. The DON stated there was potential for a negative outcome if care plans were not accurate. The DON stated the care plans should be updated and revised if any issues or problems were resolved. The DON stated that the revision of the care plan should show that the needs of the resident were being met. The DON stated the needs of the resident were not clearly communicated if the care plans were not updated. The DON stated that the care plan for Resident 120 should have been resolved when the wound was considered healed. The DON stated the nurse should have resolved Resident 120's wound care plan by the end of their shift on 1/15/25.
During a review of the facilities policy and procedure (P & P) titled Care Plan, Comprehensive, dated 12/2017, the document indicated, .resident progress is regularly evaluated, and approaches revised or updated as appropriate .problem resolution and changes in goals and approaches may be identified and initiated by any interdisciplinary team member .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to meet professional standards of practice for two of nine sampled residents (Resident 112 and Resident 306) when:
1. Resident 112 was receiving 2.5 liters per minute (LPM- a unit that expresses flow rate define) of oxygen when the continuous oxygen ordered was for 2 LPM.
2. Resident 306's oxygen flow rate was set at 3 L/min and not 2 L/min as indicated on the physician order (a set of instructions written by a doctor for clinicians to follow when caring for a resident).
These failures had the potential to result in serious health conditions for the resident including oxygen toxicity that could cause damage to lung tissue and respiratory issues.
3. Resident 306's oxygen tubing was not labeled with the date the tubing should be changed.
This failure put Resident 306 at risk of infection.
Findings:
1. During a review of Resident 112's admission Record (AR), dated 2/5/25, the AR indicated Resident 112 had a diagnosis of Chronic Obstructive Pulmonary Disease (COPD - a chronic lung disease causing difficulty in breathing), emphysema (a chronic lung disease characterized by the destruction of the air sacs in the lungs), obstructive sleep apnea (a sleep disorder characterized by repeated episodes of complete or partial blockage of the upper airway during sleep, leading to disruptions in breathing) and dependence on supplemental oxygen.
During a review of Resident 112's Order Summary, dated 12/7/24, the Order Summary, indicated, Oxygen at 2 LPM via nasal cannula continuous every shift.
During a review of Resident 112's Care Plan (CP), dated 12/7/24, the CP indicated, Focus: The resident has Emphysema/COPD Date initiated: 12/7/24 . Goal: The resident will be free of [signs and symptoms] of respiratory infections through review date .Interventions: Administer Oxygen as ordered .
During an observation on 2/3/25 at 8:45 a.m., observed Resident 112 in bed awake, wearing a nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen). Observed the oxygen rate set at 2.5 LPM.
During an observation on 2/4/25 at 8:45 a.m. observed Resident 112 asleep in bed with nasal cannula on. Observed oxygen rate set at 2.5 LPM.
During an observation on 2/5/25 at 8:12 a.m., observed Resident 112 awake in bed with nasal cannula on. Observed oxygen rate set at 2.5 LPM.
During a review of Resident 112's Medication Administration Record (MAR), dated 2/2025, the MAR indicated during day shift, Resident 112 received continuous oxygen at 2 LPM on 2/3/25, 2/4/25 and 2/5/25.
During a concurrent observation and interview on 2/5/25 at 8:21 a.m. with Registered Nurse (RN) 5, RN 5 observed the oxygen flow rate for Resident 112. RN 5 stated the oxygen flow rate is set at 3 LPM. RN 5 stated she recently checked the oxygen order and it was for 2 LPM and was unsure why Resident 112 had the oxygen rate set at 3 LPM.
During a concurrent interview and record review on 2/5/25 at 4:04 p.m. with RN 5, Resident 112's Oxygen order, dated 12/7/24 was reviewed. The Oxygen order indicated, Oxygen at 2 LPM via nasal cannula continuous every shift. RN 5 stated the order was not followed when the oxygen rate was set at 2.5 LPM and the order was for 2 LPM. RN 5 stated it was important to follow the order to know how the resident was doing with their breathing and if they were maintaining their oxygen level. RN 5 stated if the resident was receiving more oxygen than was ordered, the nurse would have to notify the doctor.
During an interview on 2/7/25 at 5:00 p.m. with the Director of Nursing (DON), the DON stated the oxygen order was not followed for Resident 112 when the resident was receiving 2.5 LPM and the order was for 2 LPM of oxygen. The DON stated the resident received more oxygen than was ordered and this could be detrimental to the resident.
During a review of the facility's policy and procedure (P&P) titled Oxygen Administration, dated 8/2014, the P&P indicated, .Procedure. 1. Check physician's order for liter flow and method of administration .
2 During a concurrent observation and interview on 2/3/25 at 10:18 a.m. with Resident 306 in Resident 306's room, Resident 306 was dressed, lying in bed with oxygen infusing via nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) at 3L/min. Resident 306's oxygen tubing was observed to be unlabeled with the date it was taken out for use. Resident 306 stated she had been at the facility for five or six days due to an inability to walk.
During a review of Resident 306's AR, dated 2/6/25, the AR indicated Resident 306 was admitted to the facility from the acute care hospital on 1/19/25 with diagnoses of Methicillin Resistant Staphylococcus Aureus (MRSA - a bacteria that does not get better with the type of antibiotics [a medication that inhibits or destroys infections caused by bacteria] that usually cure staph infections [infections that are caused by bacteria usually found on the skin or in the nose]), Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), and depression (a mental health disorder characterized by sadness or loss of interest in activities).
During a review of Resident 306's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 1/28/25, the MDS section C indicated Resident 306 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive [involving the process of thinking, learning and understanding] understanding on a scale of 1-15 ) score of 15 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which indicated Resident 306 was cognitively intact.
During a concurrent interview and record review on 2/06/25 at 10:14 a.m. with Licensed Vocational Nurse (LVN) 3, Resident 306's Clinical Physician Orders, dated 2/6/35 was reviewed. The Clinical Physician Orders indicated, . oxygen at 2 LPM via Nasal Cannula [as needed] [shortness of breath] or Oxygen Saturation [measurement of oxygen in the blood] less than 92% on [room air] . LVN 3 did not go into Resident 306's room for an observation of Resident 306's oxygen setting. LVN 3 stated he checked Resident 306 earlier that morning and Resident 306's oxygen saturation was at 96% and did not require oxygen. LVN 3 stated it was important for staff to follow physician's orders for oxygen administration. LVN 3 stated oxygen was considered a medication. LVN 3 stated nursing staff should put the oxygen tubing on residents and should set the oxygen infusion rate. LVN 3 stated there was a risk of harm to residents if nurses did not follow physician's orders.
3. During a concurrent observation and interview on 2/03/25 at 10:25 a.m. with Certified Nursing Assistant (CNA) 15 in Resident 306's room, Resident 306's oxygen tubing was observed without a date label. CNA 15 stated there was no date on the oxygen tubing indicating when it was placed or changed. CNA 15 stated the nurses dated the tubing.
During a concurrent observation and interview on 2/3/25 at 10:29 a.m. with LVN 4 in Resident 306's room, Resident 306's oxygen tubing was observed without a date label. LVN 4 stated there should have been a date on the oxygen tubing indicating when it was placed or changed. LVN 4 stated the oxygen tubing should be changed every week. LVN 4 stated a date label was needed so staff would know the last time the oxygen tubing was changed. LVN 4 stated the tubing and nasal cannula could become dirty and block the oxygen flow. LVN 4 stated a dirty cannula, and dirty tubing placed a resident at risk for infection.
During an interview on 2/06/25 at 2:51 p.m. with the Assistant Director of Nursing (ADON), the ADON stated her expectation was for oxygen tubing to be labeled with a date so staff would know when the tubing was changed and to prevent infection from soiled tubing. The ADON stated the oxygen tubing should have been changed weekly to maintain patency (being open, expanded, or unobstructed) of the tubing and to prevent kinked or soiled tubing which could be a risk for infection to the resident. The ADON stated her expectation was for the residents' oxygen flow rate to be followed as written or verbally ordered by the physician. The ADON stated if the order was not followed, there was a risk for resident's medical condition to worsen.
During a review of the facility's P&P titled, Oxygen Administration, dated 8/2014, the P&P indicated, . to administer oxygen to the resident when insufficient oxygen is being carried by the blood to the tissues . check physician's order for liter flow and method of administration . set the flow meter to the rate ordered by the physician . change humidifier and tubing per facility procedure . PRECAUTION: CONSTANT FLOW OF OXYGEN CAN CAUSE DRYING AND THICKENING OF NORMAL SECRETIONS RESULTING IN LARYNGEAL ULCERATION [an open sore on or near the vocal cords] . at regular intervals, check and clean oxygen equipment, masks, tubing and cannula .
During a review of the facility's P&P titled, Oxygen Administration per Nasal Cannula, dated 1/1/14, the P&P indicated, . a physician's order shall be required for administering oxygen . humidifier and nasal cannula shall be changed every 7 days or frequently when needed . connect the nasal cannula to the bubble humidifier and turn flow meter to flow rate ordered by the physician . documentation . date and time . method of oxygen administration and rate of flow .
During a review of the facility P&P titled, Processing Physician Orders, dated 8/2017, the P&P indicated, . to verify and maintain accuracy of physician orders to provide appropriate care . prior to saving orders to the patient record, LN's [licensed nurses] are to clarify orders with the attending physician .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of five sampled Residents (Resident 28), received toenail care consistent with professional standards of practice when Resident 28's toenails were long and jagged.
This failure resulted in Resident 28's toenails to become long, jagged, and caused discomfort which had the potential to lead to ingrown toenails, infection, and injury.
Findings:
During a review of Resident 28's admission Record (AR- document containing resident personal information), dated 11/25/24, the AR indicated, Resident 28 was admitted to the facility on [DATE], with diagnoses which included, displaced intertrochanteric fracture of right femur (a break in the bone just below the hip joint) subsequent encounter for closed fracture (a type of bone break where the broken bone does not penetrate the skin) with routine healing, muscle weakness generalized, need for assistance with personal care, and other reduced mobility.
During a review of Resident 28's Minimum Data Set (MDS- a resident assessment tool) assessment, dated 12/4/24, the MDS assessment indicated Resident 28's Brief Interview for Mental Status (BIMS- an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) assessment score was 15 out of 15 which indicated Resident 28 had no cognitive deficit (a decline in mental processes that affect a person's ability to learn, think, and understand). The MDS assessment indicated Resident 28's functional abilities (the capacity to perform daily tasks and activities) required substantial/maximal assistance (Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) for lower body dressing and putting on/taking off footwear. The MDS assessment indicated Resident 28's functional abilities required partial/moderate assistance (Helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) for personal hygiene.
During an interview on 2/3/25 at 8:24 a.m. with Resident 28, Resident 28 stated her toenails were long, jagged, and uncomfortable. Resident 28 stated she had limited range of motion (joint that has a reduced ability to move) and could not provide her own toenail care. Resident 28 stated she relied on staff to perform toenail care. Resident 28 stated she would never leave her toenails jagged, sharp, uneven and long. Resident 28 stated Certified Nursing Assistants (CNAs) and Licensed Vocational Nurses (LVNs) trimmed her toenails and left them jagged, sharp, uneven, and long. Resident 28 stated her toenails were trimmed once since admitted to the facility. Resident 28 stated her toenails had not been filed smoothly.
During an interview on 2/4/25 at 10:25 a.m. with Certified Nursing Assistant (CNA) 5, CNA 5 stated CNAs were responsible to provide routine toenail care twice a week with every shower, as needed, and when requested by the resident. CNA 5 stated toenail care included a trim, file, and cleaning underneath the toenail. CNA 5 stated toenail care was documented on the Shower Day Inspection form. CNA 5 stated if a resident was non-compliant or refused toenail care it was expected to be documented on the Shower Day Inspection form. CNA 5 stated it was expected all residents' toenails were smooth and clean. CNA 5 stated long, jagged, and sharp toenails could become dirty, ingrown, or lead to an infection.
During a concurrent observation and interview on 2/4/25 at 10:31 a.m. with Resident 28 in Resident 28's room, Resident 28's toenails were observed to be long, jagged, and uneven (all ten toes). Resident 28's right big toenail was observed longer than the other nine toenails, growing toward the right at an angle into the toe. Resident 28 stated her right big toenail was the longest and scratched her, even when wearing socks. Resident 28 stated all her toenails were sharp and it made her uncomfortable. Resident 28 stated she had to wear socks to prevent her toenails from scratching her legs and feet. Resident 28 stated she did not want to wear socks all the time. Resident 28 stated she had requested assistance to file her toenails smoothly, but it was not provided.
During an interview on 2/4/25 at 1:30 p.m. with Licensed Vocational Nurse (LVN) 6, LVN 6 stated nursing staff were responsible to provide routine toenail care. LVN 6 stated she expected CNAs to trim, file, and clean all residents toenails twice a week with each shower. LVN 6 stated she expected all residents toenail preferences and requests to be followed. LVN 6 stated toenails should not be left long, jagged or sharp. LVN 6 stated residents with long, jagged, and sharp toenails were at risk of becoming dirty and had the potential to cut the resident and cause an infection.
During a concurrent interview and record review on 2/4/25 at 3:03 p.m. with Registered Nurse(RN) 2, a photograph taken of Resident 28's toenails, dated 2/4/25, was reviewed. RN 2 stated Resident 28's toenails were long, jagged, and sharp. RN 2 stated Resident 28's right big toenail was longer than the other nine toenails, growing toward the right at an angle into the toe. RN 2 stated sharp toenails could cut Resident 28 and lead to injury or infection. RN 2 stated she expected Resident 28's toenails to be smooth and equal in length.
During an interview on 2/6/25 at 2:07 p.m. with the Director of Staff Development (DSD), the DSD stated she was responsible to provide training and education to all staff within the facility and ensured staff competency by return demonstration. The DSD stated she performed an all-staff training titled, ADL [Activities of daily living- activities related to personal care. They include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating.] Care and Call Lights, on 4/7/24 which covered toenail care. The DSD stated she expected all nursing staff to follow toenail training guidelines and facility policy. The DSD expected all resident toenails to be trimmed, filed, and cleaned twice a week with each shower, as needed, or when requested by the resident. The DSD stated CNAs were responsible to document routine toenail care on the Shower Day Inspection form and documented if the resident refused or was non-compliant with toenail care. The DSD stated resident toenails should not be long, jagged or sharp to prevent ingrown toenails, discomfort, and injury.
During a concurrent interview and record review on 2/6/25 at 5:02 p.m. with the Director of Nursing (DON), a photograph taken of Resident 28's toenails, dated 2/4/25, was reviewed. The DON stated Resident 28's toenails were long, uneven in length, jagged, and sharp. The DON stated she expected routine toenail care to be provided to all residents twice a week with each shower, as needed, or when requested by the resident. The DON stated she expected all resident toenails to be trimmed and filled smoothly. The DON stated she expected CNAs to document toenail care on the Shower Day Inspection form and document refusal or non-compliance with toenail care. The DON stated long, jagged, and sharp toenails could lead to discomfort and injury if Resident 28 scratched herself with her toenails.
During a review of Resident 28's Care Plan, dated 11/26/24, the Care Plan indicated, .Self-care deficit as evidence by: needs assistance with ADL's related to muscle weakness .personal hygiene .physical assistance required .
During a review of Resident 28's Shower Day Inspection form, dated 2/1/25, the Shower Day Inspection form indicated Resident 28's routine toenail care was not completed.
During a review of the facility's training lesson titled, ADL Care and Call Lights, undated, the ADL Care and Call Lights training lesson indicated the program was attended by all staff and taught by the DSD. The training lesson indicated, .identify ADL needs for all residents .nail care-hands and feet .daily nail cleaning should be provided to each resident, trimming and filing as needed and shower days. Toenails should be filed straight across and cleaned .
During a review of the facility's policy and procedure (P&P) titled, Activities of Daily Living (ADL's), dated 2/2023, the P&P indicated, .care and services will be provided for the following activities of daily living .grooming .a resident who is unable to carry out activities of daily living will receive the necessary services to maintain .grooming, and personal .hygiene .
During a review of the facility's P&P titled, Foot Care, dated 2006, the P&P indicated, .toenails are to be clipped and filed smoothly .to prevention infection of the feet .to prevent irritation of the feet .to prevent skin break in skin integrity of the feet .to promote cleanliness .
During a review of the facility job description document titled, Certified Nursing Assistant, dated 11/13/17, the document indicated, .The primary purpose of this position is to provide each of your assigned residents with routine daily nursing care and service .Provide .assistance and support to maintain residents ADL function .Provide the clinical and support services needed to meet all physical and psycho-social needs of the residents and patients .provide support and assistance with grooming, including shower as scheduled .and nail care .
During a review of the Nursing Times article titled, Foot Assessment and Care for Older People, dated 12/9/14, the article indicated, .Foot care is a crucial part of nursing care, particularly for older patients, who may be unable to care for their own feet .Nails that become too long .can damage the skin on adjacent toes .Ingrown toenails occur when a nail grows into the skin, and can cause pain, swelling, redness and infection .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide required treatment and services to one of five residents (Resident 20), when Resident 20 did not receive restorative nursing assistant (RNA - helps patient regain physical skills through therapeutic care including mobility exercises, dressing, eating and bathing) services ordered by the physical therapist (PT-a person qualified to treat disease, injury or deformity by physical methods such as massage, heat treatment and exercise) once PT was discontinued on 3/6/24. Resident 20 did not receive range of motion (ROM- full movement potential of a joint) treatment from 3/6/24, when Resident 20 was discharged from PT, until 2/4/25, when Resident 20 was reevaluated by an occupational therapist (OT - healthcare professional who helps individuals improve their ability to perform activities of daily living [ADL]), a time lapse of 10 months and 29 days.
These failures by PT to coordinate with RNA services to continue Resident 20's exercise treatments, potentially contributed to Resident 20 developing decreased ROM of the right hand leading to a contracture (a stiffening/shortening at any joint, that reduces the joint's ROM).
Findings:
During a concurrent observation and interview on 2/3/25 at 2:34 p.m. with Resident 20 and Resident 20's responsible party (RP - health care decision maker) in Resident 20's room, Resident 20's right hand was observed to have slight movement of the middle finger, while the other three fingers and thumb remained in a bent position and did not move. The RP stated, I visit my wife every single day and am here from 7 a.m. to 3 p.m. The RP stated Resident 20's right hand has worsened since admission. The RP stated no ROM had been done since the Resident was discharged from physical therapy in March of 2024. The RP stated he did not know why PT was no longer provided but the RP had informed staff a few months ago in a meeting about wanting treatment for Resident 20's right hand. The RP stated Resident 20's right hand was more bent than when she came into the facility, and she could no longer extend four fingers.
During a review of Resident 20's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 2/5/25, the AR indicated Resident 20 was admitted to the facility on [DATE] with a diagnosis of hemiplegia (total loss of the ability to move the arm, leg, and trunk on the same side of the body) and hemiparesis (one-sided muscle weakness) following cerebral infarction (when blood flow to the brain is interrupted, causing brain cells to die) affecting left non-dominant side and encephalopathy (a change in how the brain functions and leads to declining ability to reason and concentrate).
During a review of Doctor of Medicine/Nurse Practitioner/Physician's Assistant Progress Note (MD/NP/PA), dated 1/22/25, the MD/NP/PA Progress Note indicated, . [Resident 20] has a history of multiple strokes with right side weakness . [History] of stroke [blood flow to the brain is interrupted leading to brain cell damage and death] with right hemiparesis .
During a review of Resident 20's Care Plan (CP), dated 1/30/24, the CP indicated, Self-Care Deficit as Evidence by: Needs maximal to dependent assistance with [activities of daily living (ADL)] [related to] multiple medical conditions, *With [diagnosis] of CVA [cerebrovascular accident- known as a stroke, where blood flow to the brain is interrupted] [with/left] SIDED WEAKNESS With impaired [right lower extremity (limbs of the body, such as the arms and legs)/bilateral upper extremity (RLE/BUE)] ROM. Date initiated: 1/30/24 . Revision on 2/6/25 .
During a concurrent interview and record review on 2/7/25 at 10:02 a.m. with the Administrator (ADM), Resident 20's CP, dated 1/30/24 was reviewed. The CP indicated, .Interventions .Transfer: Two- person physical assistance required .Locomotion [movement or the ability to move from one place to another]- One- person physical assist required as needed .Bathing - One- person physical assist required . The ADM stated this CP is current. The ADM stated the CP did not state to perform ROM, but locomotion would be considered movement with raising of arms.
During a review of Resident 20's Minimum Data Set (MDS - a resident assessment tool), dated 7/19/24, the MDS indicated Resident 20's Brief Interview for Mental Status (BIMS - an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score was 3 out of 15 (0-7 indicated severe cognitive impairment [memory loss, poor decision making skills] 8-12 moderate cognitive impairment, 13-15 cognitively intact) which indicated resident had a severe cognitive impairment.
During a review of Resident 20's N Adv- Skilled Evaluation - V 16 (Evaluation), dated 1/31/24, the Evaluation indicated, the right hand was normal with no weakness, tremors (involuntary, rhythmic shaking movements that can affect various parts of the body including the hands), numbness or tingling.
During a review of Resident 20's PT Evaluation, dated 1/31/24, the PT Evaluation indicated, .Assessment summary .without skilled therapeutic intervention [a goal-oriented treatment that is tailored to a resident's needs and performed by a licensed therapist], the patient is at risk for further decline in function, decreased ability to return to prior living environment and increased dependency upon caregivers . The PT Evaluation indicated, Reason for Referral: Patient referred to PT due to new onset of increased need for assistance from others, decrease in functional mobility, compromised physical exertion level during activity, functional limitation with ambulation [ability to walk from one place to another, either independently or with the help of a device] and decrease in strength . The PT Evaluation indicated the ROM for both lower extremities were within functional limits (WFL) and strength for bilateral lower extremities (BLE) was impaired but did not indicate the ROM and strength for bilateral upper extremities (BUE).
During a review of Resident 20's Physical Therapy PT Discharge Summary, dated 3/6/24, the Physical Therapy PT Discharge Summary indicated, . Prognosis to Maintain [current level of function] = Good with strong family support, good with consistent staff follow-through .
During a review of Resident 20's Occupational Therapy OT Evaluation, dated 1/31/24, the Occupational Therapy OT Evaluation indicated, Resident 20's baseline (starting point) for upper body dressing was, Max A (51-75% assist- [PT and resident each put in about half of the effort]), Section GG: Substantial/Maximal Assist [level of assistance where a patient needs a significant amount of help to complete a task] . The Occupational Therapy OT Evaluation indicated for section musculoskeletal [having to do with muscles, bones, tendons, ligaments, joints and cartilage] ROM, [upper extremity (UE)] ROM: [right upper extremity (RUE)] ROM= Impaired . The Occupational Therapy OT Evaluation indicated, .without skilled therapeutic intervention, this patient is at risk for rehospitalization, decreased ability to return to prior level of function . decrease in level of mobility, falls, further decline in function, increased dependency upon caregivers and decreased participation in functional tasks . The Occupational Therapy OT Evaluation did not indicate ROM specifically for right hand and right fingers.
During a review of Resident 20's Occupational Therapy OT Discharge Summary, dated 3/6/24, the Occupational Therapy OT Discharge Summary indicated, . Progress & Response to Treatment: Patient responded positively to passive techniques to stimulate functional performance and enhance safety to prevent further decline . Restorative Programs. Restorative Program Established/Trained = Restorative Range of Motion Program. Range of Motion Program Established/Trained: UE ROM [performed ROM] exercises for shoulder flexion [a bending movement around a joint in a limb that decreases the angle between the bones of the limb at the joint]/extension [movement of a joint that increases the angle between the bones involved], abduction [movement of a body part away from the midline of the body], elbow flexion/extension, wrist flexion/extension, [finger] flexion .
During a review of Resident 20's Occupational Therapy OT Discharge Recertification, dated 3/6/24, the Occupational Therapy OT Discharge Recertification indicated, .Communication. Collaboration/Transition plan: Reviewed patient's plan of treatment and treatment services with interdisciplinary team members .
During a review of Resident 20's Progress Note (PN), dated 3/1/24, the PN indicated, .Functional: Able to move all extremities. Upper extremity ROM: No Impairment Physical Therapy Resident continues to participate in therapy as ordered. Occupational therapy: Resident continues to participate in therapy as ordered .
During a review of Resident 20's Restorative Therapy Referral - V 1, dated 3/6/24, the Restorative Therapy Referral - V 1 indicated, .D. RNA Program. 1. Current Problems: Patient is at elevated risk of loss of UE/ ([lower extremity (LE)] ROM and inability to tolerate upright activity. 2. Goals: Maintain current UE/LE ROM and tolerance to upright activity. 3. Approaches: Right/Left upper and lower extremity PROM to tolerance all planes [a flat surface, a cut through the body] 3 sets[group of repetitions of an exercise performed consecutively without stopping] [times] 10 [repetitions] [up in chair (UIC)] via [patient lift - a mechanical device used to lift and/or transfer a person) daily [times] 1 or to tolerance Position [right] UE with pillow between body and UE . The Restorative Therapy Referral - V 1 indicated check marks for both boxes stating, Program reviewed with RNA and training completed and RAI [Resident Assessment Instrument- tool that helps nursing home staff assess a resident's needs and strengths]/MDS made aware of transfer of care.
During a review of Resident 20's Interdisciplinary team (IDT) Assessment & Progress Note - V 3 (IDT Assessment), dated 4/24/24, the IDT Assessment indicated, Restorative Care/ PT/OT (occupational therapy)/ST (speech therapy) . 2. Functional ROM limitations . check marked for both sides-upper extremity. The IDT Assessment indicated no checkmark for current PT, OT and ST, and no checkmarks for current RNA programs including .1. Ambulation/locomotion 3. Splint [an external device used to immobilize an injury or joint /Contracture management 5. ROM 2. ADL 4. Dining . The IDT Assessment indicated, . [Resident 20] Requires maximal to dependent assist with ADL'S needs .
During a review of Resident 20's IDT Assessment & Progress Note - V 3 (IDT Assessment), dated 7/12/24, the IDT Assessment indicated, Restorative Care/ PT/OT/ST . 2. Functional ROM limitations . check marked placed for, .1. None-upper extremity 2. None-lower extremity . The IDT Assessment indicated no checkmark for current PT, OT and ST, and no checkmarks for current RNA programs including .1. Ambulation/locomotion 3. Splint/Contracture management 5. ROM 2. ADL 4. Dining .
During a review of Resident 20's IDT Assessment & Progress Note - V 4 (IDT Assessment), dated 10/11/24, the IDT Assessment indicated, Restorative Care/ PT/OT/ST . 2. Functional ROM limitations . check marked for both sides-upper extremity. The IDT Assessment indicated no checkmark for current PT, OT and ST, and no checkmarks for current RNA programs including .1. Ambulation/locomotion 3. Splint/Contracture management 5. ROM 2. ADL 4. Dining . The IDT Assessment indicated, . [Resident 20] Requires maximal to dependent assist with ADL'S needs .
During a review of IDT Assessment & Progress Note - V 4 (IDT Assessment), dated 1/9/25, the IDT Assessment indicated, Restorative Care/ PT/OT/ST . 2. Functional ROM limitations . check marked for, 2. None-Lower Extremity . 5. Both sides Upper Extremity . The IDT Assessment indicated no checkmark for current PT, OT and ST, and no checkmarks for current RNA programs including .1. Ambulation/locomotion 3. Splint/Contracture management 5. ROM 2. ADL 4. Dining . The IDT Assessment indicated, .5. New Referrals for PT/OT [evaluation] and [treatment] .
During an interview on 2/6/25 at 9:11 a.m. with Restorative Nursing Assistant (RNA) 1, RNA 1 stated, there was no RNA program for Resident 20 and a restorative therapy referral form was never received from a PT. RNA 1 stated the process of transitioning a resident from PT to the RNA program was the PT would create the restorative therapy referral form that included the RNA treatment. RNA 1 stated this form would then be printed out by the PT, provided to and reviewed with the RNA. RNA 1 stated the PT would provide instructions if needed and both the PT and RNA would sign the form and keep a copy. The RNA would then present the copy to the MDS Coordinator (a nurse who manages the assessment process for long-term care patients) to upload into Point Click Care (PCC- online charting system). RNA 1 stated once uploaded, the form was given back to the RNA and the form was stored in a binder in the RNA office. RNA 1 was unable to locate a copy of the restorative therapy referral form that would have been completed and signed by an RNA and PT on 3/6/24 for Resident 20.
During a concurrent interview and record review on 2/6/25 at 9:50 a.m. with Physical Therapist (PT) 1, Resident 20's Restorative Therapy Referral - V 1, dated 3/6/24 was reviewed. The Restorative Therapy Referral - V 1 indicated an established RNA program that specified therapy treatments to be conducted by an RNA with Resident 20.The Restorative Therapy Referral - V 1 indicated the RNA program, was reviewed with RNA and training completed . and .RAI/MDS was made aware of the transfer of care . The Restorative Therapy Referral - V 1 indicated the form was electronically signed by the physical therapist on 3/6/24 and is seen in the resident's medical record. PT 1 stated this form was signed on 3/6/24 by a temporary PT that is no longer at the facility. PT stated there is no signature by the RNA on this form. PT 1 stated there was a physical therapy evaluation done on 2/5/25 for Resident 20.
During an interview on 2/6/25 at 10:00 a.m. with Occupational Therapist (OT) 1, OT 1 stated an occupational therapy evaluation was conducted for Resident 20 on 2/4/25. OT 1 stated, I saw a new developing contracture on the resident's right hand. OT 1 stated splinting (medical procedure that involves immobilizing an injured area with a supportive device) would be done for this contracture. OT 1 stated Resident 20 will be fitted for a splint (a rigid or flexible device that maintains in position a displaced or movable part) and one would be placed.
During a review of Resident 20's MD/NP/PA Progress Note dated 1/22/25, the MD/NP/PA Progress Note indicated, . No new concern. Husband at bedside wondering if there is treatment for [Resident 20's] right hand contracture . The MD/NP/PA Progress Note indicated in the musculoskeletal category, box for negative and box for contractures were check marked and indicated .mild right-hand contracture . The MD/NP/PA Progress Note indicated in the comments section, . Right hand contracture: continue to place a rolled towel in her hand .
During an interview on 2/6/25 at 10:09 a.m. with the Assistant Director of Rehab (ADOR), the ADOR stated she was unable to locate the restorative therapy referral form in the records kept in her office for Resident 20 from 3/6/24. The ADOR stated currently there was a real change of condition conducted on 1/27/24 for Resident 20. The ADOR stated the current plan for Resident 20 was to have PT and OT services done and once these services are completed, Resident 20 would be placed in the RNA program. The ADOR stated a splint for Resident 20's RUE wrist for finger flexion will be ordered once the resident is fitted for one. The ADOR stated, I do see there is a significant change of condition for resident in development of a contracture.
During a review of Resident 20's Rehabilitation Referral, dated 1/27/25, the Rehabilitation Referral indicated for section splinting/contracture management, contracture upper (contracture found on RUE) was check marked. The Rehabilitation Referral indicated for section physical care/mobility skills box for weakness upper/lower extremities was check marked and box for limited ROM was check marked. The Rehabilitation Referral indicated, Comments: PT/OT eval for BUE/BLE strengthening.
During a concurrent interview and record review on 2/6/25 at 10:30 a.m. with the MDS Coordinator, the MDS Coordinator stated there was no RNA program done for Resident 20 when the resident was discharge from PT in March of 2024 and was unable to locate the Restorative Therapy Referral - V 1 form completed on 3/6/24. The MDS Coordinator stated the expectation was for the RNA to be informed by the PT of the restorative program, the form signed by both the RNA and PT and the form presented to MDS Coordinator to upload into PCC. The MDS Coordinator stated this process was not done and it should have been. The MDS Coordinator stated Resident 20's RP informed her, sometime in January of 2025, of Resident 20's right hand and observed it to appear different and placed an order for a PT and OT evaluation on 1/10/25. The MDS Coordinator stated, there should have been an order for ROM done by the RNA.
During a review of Resident 20's Order Details, dated 1/10/25, indicated an order for, Occupational Therapy Evaluation and Treatment was placed on 1/10/25 by the MDS Coordinator and signed by the MD on 1/14/25.
During a review of Resident 20's Order Details, dated 1/10/25, indicated an order for Physical Therapy Evaluation and Treat was placed on 1/10/25 by the MDS Coordinator and signed by the MD on 1/14/25.
During a review of Resident 20's Occupational Therapy PT Evaluation, dated 2/4/25, the Occupational Therapy PT Evaluation indicated, . RUE ROM. Hand = Impaired (Contractures developing in R [right] hand) . The Occupational Therapy PT Evaluation indicated, .RUE strength = Impaired . The Occupational Therapy PT Evaluation indicated, . Reason for Skilled Services: Patient requires skilled occupational therapy services at the prescribed frequency and duration to address the following: splinting in R hand in order to enhance this patient's quality of life by improving hand ROM. Due to the documented deficits (lacking something necessary or not meeting a standard) and the patient's complicated medical history, without skilled therapeutic intervention, this patient is at risk for contracture(s) . The Occupational Therapy PT Evaluation did not specifically mention evaluation of the fingers on the right hand.
During a review of Resident 20's Physical Therapy PT Evaluation, dated 2/5/25, the Physical Therapy PT Evaluation indicated, Reason for Referral: Patient referred to PT due to new onset of decrease in functional mobility, decreased postural alignment, decrease in strength and ROM . The Physical Therapy PT Evaluation indicated ROM for the right lower extremity (RLE) is impaired and the left lower extremity (LLE) is WFL but did not indicate ROM for both upper extremities. The Physical Therapy PT Evaluation indicated strength for both RLE and LLE was impaired but did not indicate strength for both upper extremities.
During an interview on 2/6/25 at 1:40 p.m. with the ADOR, the ADOR stated the Director of Rehab (DOR) oversaw a resident's transition from PT to the RNA program and oversight was not done for Resident 20. The ADOR stated the purpose of performing the RNA program was for the resident to maintain their current level of function once discharged from PT or OT services. The ADOR stated Resident 20 may have developed a contracture because the RNA program had not been done.
During an interview on 2/6/25 at 2:03 p.m. with the Director of Nursing (DON), the DON stated there was no policy in place for the process of transitioning a resident from PT to the RNA program.
During an interview on 2/7/25 at 1:39 p.m. with Resident 20's RP, the RP stated he noticed Resident 20's 4 fingers and right hand started to bend in June of 2024. The RP stated Resident 20 would tell him she was unable to straighten out her fingers when he would ask her to. The RP stated he notified staff about Resident 20's right hand in a meeting held about 3 months ago and in the following meeting he brought it up again because nothing had been done. The RP stated one of the social workers suggested placing a towel in Resident 20's right hand but stated, I felt like it wouldn't help because I don't want her hand like in a fist, I want it straightened out.
During an interview on 2/7/25 at 5:00 p.m. with the DON, the DON stated there was a failure by PT for not following the process of transitioning a resident from PT services to the RNA program. The DON stated the process was broken. The DON stated the importance of following the process was to make sure that the recommendation made by the PT was followed especially if the resident was not in rehab and for maintenance by the RNA, CNAs, and nurses. The DON stated she wanted the residents to maintain ADLs. The DON stated, we failed to follow the recommendation [by the PT].
During a review of the facility's policy and procedure (P&P) titled, Nursing Rehab/Restorative Care Program, (undated), the P&P indicated, The primary goal . is to ensure that all residents receive care and services that promote their ability to live and function as independently as possible; to maintain and/or improve function and prevent decline . Members of various clinical disciplines and support services use their observational and assessment skills to identify each resident's functional strengths, weaknesses and needs .For residents in a RNA program, monthly progress notes by the Restorative Nurse Aide provide specifics on delivery of Nursing Rehab and/or Restorative activities and the resident's response to them (how they are progressing toward their goals). The progress notes are signed off by restorative nurse or by state requirements .
During a review of the facility's Job Description (JD) titled, Job Description/Performance Evaluation RNA, dated 11/13/17, the JD indicated, .The primary purpose of this position is to assist in performing restorative nursing procedures that maximize the resident's existing abilities, emphasize independence, minimize the negative effects of disability with an attitude of realistic optimism .Meets with administration, nursing staff, therapy department, as well as other related departments in planning restorative care. Maintains restorative care standards . Maintains treatment grids, care plans and progress notes as required .
During a review of the facility's JD titled, .Rehabilitation Job Description for Physical Therapist, dated 12/8/15, the JD indicated, . The Physical Therapist identifies the need for and makes referral(s) to other disciplines to address the comprehensive needs of the patients. They implement individualized therapy programs designed to restore, reinforce, and enhance performance. In addition, the Physical Therapist instructs, educates and trains patients and caregivers in those skills and functions essential for promoting independence and productively, in order to diminish or correct pathology [the study of disease, including its causes, effects and progression]. They direct activities to promote and maintain health . Responsibilities/Accountabilities . 4. Makes referrals to other disciplines and agencies in order to address the comprehensive needs of the patient. 5. Consults with other members of the rehabilitation team to select the most appropriate therapeutic regimen consistent with the needs and capabilities of each patient .11 .completes all related documentation and record keeping regarding these services .15. Performs routine reexamination as needed/required to modify/progress plan of treatment .
During a review of the facility's JD titled, .Rehabilitation Job Description for Assistant Director of Rehab PT (DRAP), dated 2/20/23, the JD indicated, .This position also assists in integration of rehabilitation services in all settings .Responsibilities/Accountabilities .1. Fills in for the Director of Rehab in their absence . 6. Assists in management of therapy staff .
During a review of the facility's JD titled, .Rehabilitation Job Description for Director of Rehab PT (DRGP), dated 2/20/23, the JD indicated, .This position also assists in integration of rehabilitation services in all settings. The Director of Rehab PT ensures that the highest standard of rehabilitation services is delivered and maintained . 2. Provides direct patient care. 3. Monitors the standard of clinical services being delivered and maintained in all sites and ensures an ethical and compliant product is being delivered .
During a review of the facility's JD titled, Job Description/Performance Evaluation MDS Coordinator, dated 11/13/17, the JD indicated, The primary purpose of this position is to manage the MDS function and processes to: (1) maximize clinical outcomes for patients and residents, assuring resident safety and (2) ensure timely, accurate and complete clinical and support documentation . The JD was current during the time of Resident 20's care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure one of six sampled residents (Resident 37), was free from accidents when:
1. Resident 37's foley catheter (helps drain urine from your bladder) tubing was wrapped around her prosthetic (artificial leg that replaces the part of the leg below the knee joint) right lower leg while sitting in her wheelchair.
This failure had the likelihood to cause a fall or injury to Resident 37 via the catheter tripping her during a transfer (movement from wheelchair to bed and vice versa) or being pulled from her bladder as a result of being caught on her prosthesis (artificial leg).
Findings:
1. During a review of Resident 37's Face Sheet (a summary of important information regarding a patient which include patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 2/5/25, the Face Sheet indicated, Resident 37 was admitted to the facility on [DATE] with a diagnosis of cellulitis (a serious deep infection of the skin caused by bacteria) of the left lower limb, muscle weakness (loss of muscle strength), mild dementia (a brain condition that causes memory loss, thinking problems, and behavioral changes), neuromuscular dysfunction of the bladder (occurs when the nerves that control the bladder do not work properly) and peripheral vascular disease (a condition that occurs when blood vessels narrow or block, reducing blood flow to the arms and legs).
During a review of Resident 37's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive and physical function) assessment, dated 1/16/25, the MDS assessment indicated Resident 37's BIMS assessment score was 15 out of 15. The BIMS assessment indicated Resident 37 was cognitively intact.
During a concurrent observation and interview on 2/4/25 at 9:05 a.m. with Resident 37, in Resident 37's room, Resident 37's foley catheter tubing was wrapped around her prosthetic right lower leg. Resident 37 stated she was unaware the tubing was wrapped around her leg. Resident 37 stated the tubing could make me fall or pulled out. Resident 37 stated I could have got hurt.
During a concurrent observation and interview on 2/4/25 at 9:15 a.m. with CNA 11, in Resident 37's room, Resident 37's foley catheter tubing was wrapped around her prosthetic right lower leg. CNA 11 stated the catheter was a trip hazard for the resident and should not have been wrapped around her lower leg. CNA 11 stated Resident 37 was moved to her wheelchair from her bed this morning by the physical therapy department.
During an interview on 2/4/25 at 12:01 p.m. with PTA 2, PTA 2 stated he transferred Resident 37 from her bed to her wheelchair that morning and moved her foley catheter to the wheelchair. PTA 2 stated her foley catheter should not have been wrapped around her prosthetic leg and was not sure when that happened. PTA 2 stated the expectation was for the foley catheter to not be a trip hazard but it was. PTA 2 stated Resident 37 was not safe. PTA 2 stated he was never trained on where to place the foley catheter on Resident 37's wheelchair.
During an interview on 2/6/25 at 10:27 a.m. with RN 3, RN 3 stated Resident 37 was at high risk for a fall with the foley catheter like that. RN 3 stated the foley catheter should have been attached to her left leg. RN 3 stated Resident 37's catheter was dangerous and she could have fell. RN 3 stated Resident 37 also could have had her catheter pulled out and suffered a bladder injury.
During an interview on 2/6/25 at 11:07 a.m. with the Director of Staff Development (DSD), the DSD stated all staff needed to know how to safely manage a resident's foley catheter. The DSD stated the foley catheter should not have been wrapped around Resident 37's leg.
During an interview on 2/6/25 at 1:59 p.m. with the Assistant Director of Rehabilitation (ADR), the ADR stated she was in charge of PTA's. The ADR stated the PTA's get informal verbal training and did not have record of it. The ADR stated Resident 37 could have fell and get a fracture (broken bone). The ADR stated all staff at the facility had to abide by all facility policy and procedures.
During an interview on 2/7/25 at 2:15 p.m. with the Infection Preventionist (IP), the IP stated the foley tubing wrapped around Resident 37's prosthetic leg could lead to unwanted tugs and increased risk for resident injury. The IP stated Resident 37 could have got injured due to a fall and had a potential hospitalization. The IP stated the foley catheter was a hazard due to its placement and staff did not follow the facilities policy and procedures Falls Management and Incident Management Policy.
During an interview on 2/7/25 at 4:35 p.m. with the DON, the DON stated the foley catheter around Resident 37's leg was dangerous and could have gotten tangled, which would have resulted in a fall. The DON stated facility staff did not follow the policy and procedures, Falls Management and Incident Management Policy.
During a review of the facility's P&P titled, Incident Management Policy, dated 10/2017, the P&P indicated, .To promptly acknowledge . individuals are identified and addressed to analyze contributing factors and environmental conditions . in order to provide a safe environment and reduce incidence of reoccurrence .
During a review of the facility's P&P titled, Incident Management Policy, dated 10/2010, the P&P indicated, .Purpose: to evaluate risk factors and provide interventions to minimize risk, injury and occurrences .

Based on observations, interview, and record review the facility failed to post the total number of licensed and unlicensed staff and actual hours worked when the posting did not represent the actual hours worked by direct care staff daily.
This failure resulted in all residents and their family members to not have access to view the actual direct care staff hours and total number of direct care staff providing care daily and possibly not meeting the needs of the residents.
Findings:
During an observation on 2/6/25 at 2:35 p.m. in the hallway, the Census and Direct Care Services Hours Per Patient Day (DHPPD) form (a document used in healthcare facilities, to track the total number of direct care hours provided to patients each day) did not contain the total number and the actual hours worked by Registered Nurses (RN), Licensed Vocational Nurses (LVN) and Certified Nursing Assistants (CNA).
During an interview on 2/6/25 3:46 p.m. with the Assistant Staff Development Coordinator (ASDC), the ASDC stated she was responsible for filling out the DHPPD form. The ASDC stated, I cannot tell you how many hours were provided by the RNs or LVNs by looking at the form we posted. The ASDC stated, I would have to look at the PPD [Per Patient Day] hours work sheet and this sheet is only available for me to see and not posted. The ASDC stated it was important to post hours to indicate how many hours were worked by the facility direct care staff. The ASDC stated, it was important to know the census in order to provide enough staffing hours for the residents. The ASDC stated, the staffing department was responsible to post the hours worked by the facility direct care staff. The ASDC stated, Residents and families have a right to know the information.
During an interview on 2/6/25 at 4:05 p.m. with the Administrator (ADM), the ADM stated, the DHPPD form did not contain the hours of RNs and LVNs. The ADM stated the public had the right to know how many RN and LVN hours were worked per day. The ADM stated it was not posted and should have been posted. The ADM stated the facility used a form provided by California Department of Public Health (CDPH- the state department responsible for public health in California). The ADM stated he was not aware of the requirement by Centers for Medicare & Medicaid Services (CMS-the federal agency that provides health coverage to more than 160 million through Medicare, Medicaid, the Children's Health Insurance Program).
During a review of the professional reference titled, State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities retrieved from, chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.cms.gov/medicare/provider-enrollment-and-certification/guidancefo, the article indicated, . The facility must post the following information on a daily basis: (i)Facility name. (ii)The current date. (iii)The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: (A)Registered nurses. (B)Licensed practical nurses or licensed vocational nurses (as defined under State law). (C)Certified nurse aides. (iv)Resident census .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide a drug regimen which was free from unnecessary drugs for one of six sampled residents (Resident 3) when Resident 3 was administered mirtazapine (a medication used to treat depression [a condition characterized by extreme sadness]) from 11/2/24 to 2/6/24 without any documented attempts at a gradual dose reduction (GDR- a system used to slowly stop the use of medication over time).
This failure had the potential of causing Resident 3 to receive unwanted side effects such as dry mouth, dizziness, constipation, drowsiness, and headaches as a result of being given the mirtazapine unnecessarily.
Findings:
During a review of Resident 3's admission Record (AR- a document that
provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 2/6/25, the AR indicated, Resident 3 was admitted to the facility with diagnoses of depression and anxiety (a mental health disorder characterized by feelings of worry or fear that are strong enough to interfere with one's daily activities).
During a concurrent interview and record review on 2/6/25 at 10:25 a.m. with Licensed Vocational Nurse (LVN) 3, Resident 3's Clinical Record (CR), dated 2/6/25, was reviewed. The CR indicated Resident 3 was administered mirtazapine every day during 11/24 following his admission on [DATE], everyday 12/24, everyday 1/25, and all but one day 2/1/25 to 2/5/25. LVN 3 stated Resident 3 regularly received mirtazapine, and he would have benefitted from a GDR since he had no recorded depressive episodes. LVN 3 stated no GDR attempt was documented on Resident 3's CR. LVN 3 stated it was important to document GDR's because it ensured residents did not receive unnecessary medication.
During a concurrent interview on 2/6/25 at 11:57 a.m. with the Social Services Director (SSD) and the Director of Nursing (DON), the SSD stated Resident 3 had not had a GDR attempted since his admission on [DATE] . The DON stated the last medication review was done on 11/24, but no GDR was recommended. The SSD stated she did not properly document the doctor's recommendation regarding a GDR for Resident 3. The SSD stated she should have documented the phone discussion with the doctor regarding the GDR because it would have explained why a GDR was not done. The DON stated it was important to document whether or not a GDR was done because it ensured residents were not administered unnecessary medication(s), which could possibly cause side effects.
During a review of the facility's policy and procedure (P&P) titled, Psychotropic Medication Management, dated 12/17, the P&P indicated, .Psychotropic Medications should only be used when necessary to minimize or eliminate medical symptoms and promote/maintain a Resident's highest practicable mental, physical, and psychosocial well being . IDT (interdisciplinary team) should evaluate psychotropic effectiveness (towards therapeutic goals), any medication related adverse consequences, functional changes, and continued necessity at least quarterly . Documentation guidelines (Documentation may include): . GDR assessment forms .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to properly store, and label drugs and supplies in accordance with acceptable standards of practice when:
1.
Two inhalers did not have an open date and expiration date for two of 16 sampled residents (Resident 507 and Resident 36).
2.
Two of four sampled refrigerators' temperatures were not within parameters that stored three residents (Resident 558, Resident 138, and Resident 506) medications.
These failures had the potential to place Residents at risk of receiving spoiled, expired, and ineffective medications and placed Residents at risk for experiencing adverse reactions (define) from spoiled, expired and ineffective medications.
Findings:
1.
During a concurrent observation and interview on 02/04/25 at 3:01 p.m. with Licensed Vocational Nurse (LVN) 3 in Station 1 medication cart, an inhaler (a small, handheld device that delivers medications directly into the lungs) of fluticasone (define), umeclidinium (define), and vilanterol (medications to help with Chronic Obstructive Pulmonary Disease [COPD-a lung disease that makes it hard to breathe]) was not dated with the open date or expiration date. LVN3 stated, the inhaler should have been labeled with the open date and expiration date. LVN 3 stated, it was important for the inhaler to be dated to ensure potency (effectiveness) of Resident 507's inhaler medication
During a concurrent observation and interview on 02/05/25 at 8:43 a.m. with LVN 1 in Station 4 medication cart, an inhaler of calcitonin-salmon (a medication used to treat osteoporosis [brittle bones]) that belonged to Resident 36 was not labeled with the open date or expiration date. LVN 1 stated, any new medications when opened must be labeled with the open date and expiration date on both the box and inhaler. LVN 1 stated, it was important to label medications with the open and expiration date to ensure residents were not administered expired medications. LVN 1 stated, expired medications would not have been effective and could potentially have caused adverse reactions.
During an interview on 02/06/25 at 12:00 p.m. with the Director of Infection Prevention (DIP), the DIP stated, when opened, inhalers should have been labeled with an open date and expiration date. The DIP stated, expired medications could have degraded (reduced in quality and effectiveness) and would no longer be effective. The DIP stated, it was important to label inhalers with opened and expired dates to ensure the medication's potency and avoid potential adverse effects.
During a record review of Resident 507's admission Record (AR), dated 02/05/25, the AR indicated, Resident 507 was admitted on [DATE] with a diagnosis of asthma (a chronic disease in which the bronchial airways in the lungs become narrowed and swollen, making it difficult to breathe).
During a review of Resident 507's Order Summary Report (OSR), dated, 02/06/25, the OSR indicated, .[brand name] Inhalation Aerosol (a substance consisting of very fine particles of a liquid or solid suspended in a gas) Powder Breath Activated 100-62.5-25 .(Fluticasone-Umeclidinium-Vilanterol) 1 puff inhale orally (by mouth) one time a day for UNSPECIFIED ASTHMA .
During a review of Resident 36's AR dated 02/06/25, the AR indicated, Resident 36 was admitted on [DATE] with a diagnosis of age-related osteoporosis.
During a review of Resident 36's Clinical Physician Orders (CPO) dated 02/06/25, the CPO indicated, . [brand name] solution 200 UNIT .(calcitonin (Salmon)) .
During a review of Resident 36's Medication Administration Record (MAR) dated 02/01/25-02/28/25, the MAR indicated, . [brand name] solution 200 UNIT .(Calcitonin (Salmon)) .1 spray alternating nostrils one time a day .for OSTEOPEROSIS .
During a review of the facility's policy and procedure (P&P) titled, General Dose Preparation and Medication Administration, dated 2013, the P&P indicated, .facility staff should not administer a medication if the medication or prescription label is missing or illegible .Facility staff may record the expiration date based on date opened on the label of medications with shortened expiration dates .Check the expiration date on the medication .
2.
During a concurrent observation and interview on 02/05/25 at 8:59 a.m. with LVN 1, in Station 4 medication room's refrigerator, LVN 1 stated, the temperature inside the refrigerator according to the thermometer inside the refrigerator indicated it was 30°F (degrees Fahrenheit-a unit of measure). LVN 1 stated, the temperature range of the refrigerator should have been between 36°F to 46°F. LVN 1 stated, the refrigerator temperature of 30°F was below the appropriate range of 36°F to 46°F.
During a concurrent observation and interview on 02/05/25 at 9:18 a.m. with the Assistant Director of Nursing (ADON) in Station 1 medication room refrigerator, the refrigerator thermometer inside indicated the temperature was 48°F. The ADON stated, .it should not be above 46°F . The ADON stated, the refrigerator temperature was out of range. The ADON stated, it was important to keep the temperature range between 36°F to 46°F to ensure the medications stored were stable and potency could be preserved. The ADON stated, the medications inside were: cyanocobalamin (a type of vitamin), a probiotic (live microorganisms that are beneficial) epoetin alfa (medication that treats anemia [not enough red blood cells], tuberculin purified derivative (a skin test is a test that determines if you have tuberculosis [disease that affects the lungs]), evolocumab injection (a medication used to treat hyperlipidemia-[high levels of fat in the blood]), Influenza vaccine (an injection to help prevent flu-[an infection of the nose, throat, and lungs]), and an E-Kit (Emergency Kit- small supply of medications kept in the home to quickly treat symptoms that may occur) that contained lorazepam (a medication to treat anxiety), Humulin R (a medication that treats diabetes-high levels of sugar in the blood) insulin lispro (a medication that treats diabetes), Novolin NPH (a medication that treats diabetes). The ADON stated, the Cyanocobalamin belonged to Resident 558, the epoetin alfa belonged to Resident 138, and the evolocumab injection belonged to Resident 506.
During a concurrent observation and interview on 02/05/25 at 1:31 p.m. with the ADON in Station 4's medication room, the thermometer indicated 32°F. The ADON stated, the temperature was still below the range of 36°F to 46°F. The ADON stated, she will re-adjust the temperature control and recheck.
During a concurrent observation and interview on 02/05/25 at 1:39 p.m. with the ADON in Station 1's medication room, the thermometer indicated 60°F. A temp gun (a point-and-click handheld gun that you can point at a non-organic surface to receive a temperature reading) was used to verify the thermometer reading and the temp gun indicated 51°F-61°F. The ADON stated, this refrigerator should have been replaced.
During a concurrent observation and interview on 02/05/25 at 3:06 p.m. with the ADON in Station 1's medication room , the thermometer in the refrigerator indicated a temperature of 60°FThe ADON stated, the refrigerator was replaced 15 minutes ago. The ADON stated, the new refrigerator's temperature was 60°F. A temp gun was used to verify the temperature inside and it indicated 51°F. The ADON stated, the temperature was not in parameter.
During an interview on 02/05/25 at 4:36 p.m. with the Director of Nursing (DON), the DON stated, the refrigerator in Station 1 medication room was out of range for six hours and 30 minutes. The DON stated, the refrigerator temperatures should not have been out of range to preserve the medications stored in it. The DON stated, the medications stored in the Station 1 refrigerator were discarded and replaced. The DON stated, medications not stored properly could potentially lose their potency and may cause adverse reactions.
During an interview on 02/25/25 at 12:05 p.m. with the DIP, the DIP stated, medications not stored at the correct temperature could potentially degrade. The DIP stated, degraded medications would not have been effective and could have potentially caused adverse reactions to the residents.
During a review of Resident 558's AR, dated 02/06/25, the AR indicated, Resident 558 was admitted on [DATE] with a diagnosis of autoimmune anemia (a condition where the immune system destroys red blood cells), vitamin b12 deficiency anemia (a condition when the body cannot make enough red blood cells because it does not have enough vitamin b12, and anemia).
During a review of Resident 558's CPO, dated 02/06/25, the CPO indicated, . cyanobalamin solution 1000 [Micrograms (MCG)-a unit of measure] .inject 1 [milliliter-(ml) a unit of measure] .
During a review of Resident 138's AR, dated 02/06/25, the AR indicated, Resident 138 was admitted on [DATE] with a diagnosis of end stage renal disease ( kidneys no longer work as they should) and anemia in chronic kidney disease (low red blood cell counts due to diseased kidneys).
During a review of Resident 138's CPO, dated 02/06/25, the CPO indicated, . [brand name] 10,000 units inject 1ml SQ (subcutaneous-under the skin) every Monday, Wednesday, and Friday to be given at dialysis (a type of treatment that helps your body remove extra fluid and waste products from your blood when the kidneys are not able to) .
During a review of Resident 506's AR, dated 02/06/25, the AR indicated, Resident 506 was admitted on [DATE] with a diagnosis of hyperlipidemia.
During a review of Resident 506's CPO, dated 02/06/25, the CPO indicated, . [brand name] Subcutaneous [under the skin] Solution .140[milligram/milliliter(MG/ML)-a unit of measure] [Evolocumab] .
During a review of the facility's P&P titled, Storage and Expiration of Medications, Biologicals (medications derived from living organisms), Syringes, and Needles, dated 2013, the P&P indicated, .facility should ensure .products and supplies are stored .under appropriate temperature and sterility conditions, according to the manufacturer's or supplier's recommendations .facility should ensure that medications and biologicals are stored at their appropriate temperatures .Refrigeration .36°F to 46°F .Facility personnel should inspect nursing station storage areas for proper storage compliance on a regularly scheduled basis .

Based on observation, interview, and record review the facility cook staff failed to accurately measure milk and margarine when preparing the pureed rice recipe for 12 of 12 sampled Residents (Resident 64, 505, 78, 95, 9, 96, 111, 123, 65, 93, 74, 85) with a pureed diet order.
This failure had the potential to result in 12 Residents (Resident 64, 505, 78, 95, 9, 96, 111, 123, 65, 93, 74, 85) to receive reduced or excess amount of nutrients in their food potentially leading to unexpected weight loss or weight gain.
Findings:
During a concurrent observation and interview on 2/4/25 at 10:28 a.m. with the [NAME] (COOK) 1 in the kitchen, COOK 1 measured 1.5 cup of milk using the 1/2 cup metal measuring cup three times, and the milk did not level to the top edge of the measuring cup for each measurement. COOK 1 placed a round plastic measuring cup that was larger than the width of the square block of margarine, pushed the measuring cup completely through the block of margarine leaving open areas between the block and measuring cup wall, and the margarine was not pushed down to ensure the ¾ cup measurement was accurate. COOK 1 flipped the measuring cup over and placed the margarine into the blender. COOK 1 blended all ingredients for 15 to 30 seconds then stopped the blender to open and check the pureed texture. COOK 1 would add ½ cup of milk each time the blended ingredients did not achieve the targeted pudding texture. COOK 1 added a total of 2 additional cups of 2% milk before the pureed rice achieved a pudding texture. COOK 1 stated, it was important to follow the recipe as written to ensure the pureed food had the targeted pudding consistency. COOK 1 stated if the pureed consistency was too thick, the resident could choke and if the receipt was not followed, it could have led to reduced or excess nutrients in the food which could result in resident weight loss or weight gain.
During an interview on 2/5/25 at 9:43 a.m. with the Registered Dietician (RD) in the RD office, the RD stated it was important for the cook to follow the pureed recipes to ensure the right consistency was achieved. The RD stated if the recipe was not measured or followed exactly, the food would not have the correct consistency. The RD stated for pureed rice, she would expect the cook to add more liquid than noted on the recipe to ensure the proper pureed consistency was achieved. The RD stated additional 2% milk would not increase the protein content significantly and would not harm the residents. The RD stated she expected the margarine to be measured in a cup and expected the cook to fill the measuring cup completely to ensure there was an accurate measurement (leaving no gaps between the cup and the margarine). The RD stated she had not thought to verify whether staff were properly measuring ingredients. The RD stated she should observe all staff for proper measuring as she was responsible to oversee the whole kitchen department.
During an interview on 2/5/25 at 11:23 a.m. with the Director of Nursing (DON) in the DON office, the DON stated the facility did not have a policy & procedure for pureed food preparation. The DON stated the facility expected the cook to follow the recipes.
During an interview on 2/6/25 at 9:57 a.m. with COOK 2 in the kitchen, COOK2 stated he just prepared pureed white rice for lunch. COOK 2 stated he prepared 13 servings as there were 12 residents on a pureed diet. COOK 2 stated he measured 13.5 cups of rice, 1 ¼ cup 2% milk and ½ cup + 3 tablespoons of margarine. COOK 2 stated he used the cylinder plastic measuring cup for the milk because it was numbered. COOK 2 stated he measured melted margarine as it was easier to blend. COOK 2 stated if he measured solid margarine, he would use a measuring cup and push down the margarine to ensure all sides of the measuring cup was filled to ensure accurate measurement. COOK 2 stated the risk of not ensuring ingredients were measured correctly could lead to the resident's meal losing fat content or decrease nutritive value (the amount of carbohydrates, fats, proteins, vitamins, minerals that the body uses for energy and growth). COOK 2 stated if additional liquid was needed to achieve the targeted consistency, COOK 2 would add liquid as stated on the recipe (example: 2% milk for the pureed rice recipe).
During a review of Resident Listing Report-Diet Order, dated 2/6/25, the Resident Listing Report-Diet Order indicated the facility had 12 residents with a pureed diet order.
During a review of [Name of facility] Winter 2025 Diet Spreadsheet X-format, dated 2/4/25, the lunch menu indicated the pureed diet residents would be served white rice puree.
During a review of [Name of Brand] Production Recipe, dated 2/4/25, the RICE SCR PU recipe indicated yield 16 servings: portions 16 #10 scoop; ingredients & instructions: rice 16 ½ cup, 2% milk 1 ½ cup, margarine ¾ cup +1 Tablespoon (Tbsp). 2. Process cooked rice until smooth .
During a review of Job Description/Performance Evaluation, dated 11/13/17, the Job Title: Cook indicated a key/essential duty prepare food as assigned and by .standardized recipes and facility procedures; .prepare and serve food in accordance with .recipes .
During a review of Job Description/Performance Evaluation, dated 11/13/17, the Job Title: Manager, Dietary indicated a key/essential duty all meals are properly prepared for each resident .
During a review of Job Description/Performance Evaluation, dated 11/13/17, the Job Title: Registered Dietician indicated a key essential duty evaluates and monitors the operations of the Dietary Department to assure the provision of adequate, high-quality food .

Based on observation, interview, and record review, the facility failed to maintain safe and sanitary food preparation and storage practices when:
1.
A box of potatoes was not labeled with a received date or use-by date.
2.
A dietary aide failed to wash their hands after scratching their ear and continued to place clean cups in a clean crate.
3.
Thawing frozen beef kabobs were not labeled with the prepared by or use-by date, was found in the walk-in refrigerator.
4.
Dust was identified on the ceiling above the fan in the food storage room.
These failures had the potential to cause food borne illness to a highly susceptible population of 163 residents who received food from the kitchen.
Findings:
1.
During a concurrent observation and interview on 2/3/25 at 8:02 a.m. with the Dietary Manager (DM) in the kitchen, raw potatoes were stored in an uncovered box without a label identifying the received date or use-by date. The DM stated the box of potatoes were not dated. The DM stated all food should be dated so kitchen staff knew how long food had been on the shelf. The DM stated old food could grow germs (such as salmonella-a bacterial infection that causes diarrhea, vomiting, fever and stomach cramps) which had the potential to cause medically fragile residents to get sick.
During an interview on 2/5/25 at 9:43 a.m. with the Registered Dietician (RD) in the RD office, the RD stated she expected all food to be labeled and dated. The RD stated if staff did not label or date food, they would not be compliant with facility policy. The RD stated unlabeled or undated foods created a potential risk of kitchen staff not knowing when food may have expired or spoiled. The RD stated if residents were served expired or spoiled food, the residents could develop food borne illnesses.
During a review of the facility's Job Description/Performance Evaluation, dated 11/13/17, the Job Title: Manager, Dietary indicated the primary purpose of the DM, .is to lead and manage the Dietary Department .Key/essential duties .All food storage meets regulation and standards. All kitchen and storage area meets regulations and standards .Comply with all [name of facility] policies and procedures. Demonstrate key competencies as required by the position and in accordance with State/Federal regulations.
During a review of Job Description/Performance Evaluation, dated 11/13/17, the Job Title: Registered Dietician (RD) indicated, .key/essential duties: Evaluates and monitors the operations of Dietary Department to assure the provision of adequate, high-quality food .Monitors and recommends food service standards of sanitation, safety and infection control . Comply with all Covenant Care policies, procedures, and standards .
During a review of the facility's policy and procedure (P&P) titled, Food Safety in Receiving and Storage, dated 2/09, the P&P indicated, .receiving guidelines .2. Expiration dates and use-by dates will be checked to assure the dates are within acceptable parameters .
2.
During a concurrent observation and interview on 2/3/25 at 8:05 a.m. with the DM in the kitchen, a dietary aide scratched his ear and continued to place clean cups in a clean crate without washing his hands. The DM stated staff should wash their hands after they touched their head/face before resuming tasks to prevent cross contamination (accidentally transferring harmful bacteria or allergens from one food or surface to another). The DM stated if the facility used contaminated cups, there would be potential for residents to get sick due to cross contamination.
During an interview on 2/4/25 at 9:49 a.m. with Dietary Aide (DA) 2, DA 2 stated if she touched her face while working, she would wash her hands before resuming her tasks. DA 2 stated the risk of not washing her hands could lead to cross contamination of the clean dishes which could lead to resident illness if residents were served food on contaminated dishes.
During an interview on 2/5/25 at 9:43 a.m. with the RD, the RD stated she oversees all staff in the kitchen department. The RD stated staff were expected to wash their hands before performing tasks. The RD stated if staff were to scratch their face or ear, she would expect them to wash their hands to promote infection control and food safety practices. The RD stated if staff did not wash their hands after scratching their head or ear, the potential harm to residents could result in acquiring a food borne illness.
During a review of the facility's Job Description/Performance Evaluation, dated 11/13/17, the Job Title: Dietary Aide indicated, .the primary purpose of the position is to provide assistance in all dietary functions as directed/instructed and in accordance with established dietary policies and procedures. key/essential duties .use proper hand washing procedures and wash hands often; adhere to universal precautions and sanitary and infection control policies and procedures; adheres to sanitary infection control policies with clean and dirty dishes .
During a review of the facility's Job Description/Performance Evaluation, dated 11/13/17, the Job Title: Manager, Dietary indicated, .the primary purpose of the DM .is to lead and manage the Dietary Department .Key/essential duties .All food storage meets regulation and standards. All kitchen and storage area meets regulations and standards .Comply with all Covenant Care policies and procedures. Demonstrate key competencies as required by the position and in accordance with State/Federal regulations.
During a review of the facility's Job Description/Performance Evaluation, dated 11/13/17, the Job Title: Registered Dietician (RD) indicated, .key/essential duties: Evaluates and monitors the operations of Dietary Department to assure the provision of adequate, high-quality food .Monitors and recommends food service standards of sanitation, safety and infection control . Comply with all Covenant Care policies, procedures, and standards .
During a review of the facility's P&P titled, Personnel Sanitation Standards, dated 2/09, the P&P indicated, .food and dining services personnel follow sanitary standards and practices. 3.0 Procedure: 1. food .personnel .will be required to adhere to the following sanitary standards: c. Hands must be washed .after touching the hair, mouth or nose, and at any other time it is necessary. D. Food .personnel must avoid personal habits such as touching face .when working in the food service area .
3.
During a concurrent observation and interview on 2/3/25 at 8:10 a.m. with the DM in the kitchen, unlabeled and undated sealed, packaged, frozen meat was thawing in plastic bins on the bottom shelf of the walk-in refrigerator. The DM stated she had placed the frozen beef kabobs in the refrigerator the previous night and should have labeled and dated the kebobs. The DM stated all food should be labeled and dated to indicate the prepare by and use-by date. The DM stated the potential risk of not labeling food was, the kitchen staff could use old food as they would not know how long the food had been on the shelf. The DM stated old food could grow germs and if residents were served contaminated food, there could be potential for medically fragile residents to become ill.
During an interview on 2/4/25 at 9:34 a.m. with COOK 1 in the kitchen, COOK 1 stated frozen meat should be labeled when thawed in the refrigerator overnight to be used the next day. COOK 1 stated if residents were served old food, the food could be contaminated which may cause resident sickness.
During an interview on 2/5/25 at 9:43 a.m. with the RD in the RD's office in the kitchen, the RD stated she expected all food to be labeled and dated. The RD stated if staff did not label or date food, they would not be following facility policy. The RD stated unlabeled or undated foods created a potential risk of kitchen staff not knowing when food had expired or spoiled. The RD stated if residents were served expired or spoiled food, the residents could develop food borne illness.
During a review of the facility's Job Description/Performance Evaluation, dated 11/13/17, the Job Title: Cook indicated, .key/essential duties: provide all dietary services in a safe manner and use proper sanitation and infection control measures .proper food handling, labeling with dates, and storage of all food items .
During a review of the facility's Job Description/Performance Evaluation, dated 11/13/17, the Job Title: Manager, Dietary indicated, .the primary purpose of the DM .is to lead and manage the Dietary Department .Key/essential duties .All food storage meets regulation and standards. All kitchen and storage area meets regulations and standards .Comply with all Covenant Care policies and procedures. Demonstrate key competencies as required by the position and in accordance with State/Federal regulations.
During a review of the facility's Job Description/Performance Evaluation, dated 11/13/17, the Job Title: Registered Dietician (RD) indicated, .key/essential duties: Evaluates and monitors the operations of Dietary Department to assure the provision of adequate, high-quality food .Monitors and recommends food service standards of sanitation, safety and infection control . Comply with all Covenant Care policies, procedures, and standards .
During a review of the facility's P&P titled, Food Safety in Receiving and Storage, dated 2/09, the P&P indicated, .3. Food that is repackaged will be placed in a leak-proof .container .the container will be labeled with name of the contents and dated with the date it was transferred to the new container .
4.
During a concurrent observation and interview on 2/3/25 at 8:20 a.m. with the DM in the food storage room, fine dark brown particles were identified on the ceiling above the storage room fan. The DM stated the fine dark particles were dust and the maintenance department was responsible to clean the fan and ceiling. The DM stated the risk of having dust in the storage room could result in poor circulation, which could affect temperature control thereby leading to spoiled food. The DM stated if spoiled food was served to the residents, the residents could develop food borne illnesses.
During an interview on 2/4/25 at 3:02 p.m. with the Supervisor of Maintenance (MS), the MS stated maintenance department staff were responsible to clean the kitchen condenser fans in the storage room. The MS stated he was made aware of dust identified on the ceiling above the fan in the storage room. The MS stated the fan should be cleaned once a month or more often as needed. The MS stated a newly hired maintenance worker was assigned to clean the storage room fan and wiped the fan as instructed. The MS stated the maintenance worker was not instructed to wipe the dust on the ceiling. The MS stated he expected the maintenance worker to clean all dust from the food storage area which included the fans, the ceiling, and the walls. The MS stated dust in the storage room could create a fire hazard for the facility.
During an interview on 2/5/25 at 9:43 a.m. with the RD in the RD's office in the kitchen, the RD stated the food storage area should be cleaned daily. The RD stated dust should not be on the ceiling as it may contaminate food which could lead to food borne illnesses for residents.
During a review of the facility's Job Description/Performance Evaluation, dated 11/13/17, the Job Title: Manager, Dietary indicated, .the primary purpose of the DM .is to lead and manage the Dietary Department .Key/essential duties .All food storage meets regulation and standards. All kitchen and storage area meets regulations and standards .Comply with all Covenant Care policies and procedures. Demonstrate key competencies as required by the position and in accordance with State/Federal regulations.
During a review of the facility's Job Description/Performance Evaluation, dated 11/13/17, the Job Title: Registered Dietician (RD) indicated, .key/essential duties: Evaluates and monitors the operations of Dietary Department to assure the provision of adequate, high-quality food .Monitors and recommends food service standards of sanitation, safety and infection control . Comply with all Covenant Care policies, procedures, and standards .
During a review of the facility's Job Description/Performance Evaluation, dated (date), the Job Title: Supervisor, Maintenance (MS) indicated, .the primary purpose of this position is to lead and supervise the Maintenance function by utilizing available resources to ensure that the grounds, facility, equipment and mechanical systems function in accordance with federal, state and local standards, guidelines, and regulations and to assure the facility is maintained in a safe and effective manner. key/essential duties .ensure all required preventative maintenance is timely and effectively completed; survey-substantial compliance; comply with and supervise others to comply with .all laws and regulations; comply with all [name of facility] policies and procedures.
During a review of the facility's P&P titled, Kitchen Sanitation & Cleaning Schedules, dated 2/09, the P&P indicated the facility was to, .ensure a clean and sanitary food environment. The P&P indicated, .1. The Food and Dining Services Manager develops, implements and monitors a cleaning schedule that assigns specific cleaning responsibilities to specific individuals .3.0 Procedure .6. All floors in the food .storage areas are washable .Walls and ceilings are also washable .
During a review of the professional reference titled, 2022 Food Code U.S. Food and Drug Administration, dated 1/18/23, (found at https://www.fda.gov/media/164194/download?attachment) the reference indicated, .3-305.11 Food Storage .food shall be protected from contamination by storing the food: (2) where it is not exposed to .dust, or other contamination . Preventing contamination from the premises .pathogens can contaminate and/or grow in food that is not stored properly .drafts of unfiltered air can be sources of microbial contamination for stored food .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure accurate and complete medical records in accordance with professional standards of practice were maintained for one of five sampled residents Resident 306, when the Physician Orders for Life-Sustaining Treatment (POLST- a form that contains written medical orders for healthcare professionals regarding specific medical treatments that can or cannot be done at the end-of life) was not complete.
This failure had the potential for Resident 306's decisions regarding treatment options and end of life wishes to not be honored.
Findings:
During a concurrent observation and interview on [DATE] at 10:18 a.m. with Resident 306 in Resident 306's room, Resident 306 was observed dressed, lying in bed with oxygen infusing via nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) at 3L/min (Liters per minute - a unit of measurement). Resident 306 stated she had been at the facility for five or six days due to inability to walk.
During a review of Resident 306's AR, dated [DATE], the AR indicated Resident 306 was admitted to the facility from the acute care hospital on [DATE] with diagnoses of Methicillin Resistant Staphylococcus Aureus (MRSA - a bacteria that does not get better with the type of antibiotics [a medication that inhibits or destroys infections caused by bacteria] that usually cure staph infections [infections that are caused by bacteria usually found on the skin or in the nose]), Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), and depression (a mental health disorder characterized by persistently depressed mood or loss of interest in activities).
During a review of Resident 306's MDS, dated [DATE], the MDS section C indicated Resident 86 had a BIMS score of 15, which indicated Resident 86 was cognitively intact.
During a review of Resident 306's Clinical Physician Orders, dated [DATE], the Clinical Physician Orders indicated, . do not resuscitate (DNR) . revision date . [DATE] .
During a concurrent interview and record review on [DATE] at 1:35 p.m. with the MRA, Resident 306's chart was reviewed. The MRA stated there was no completed POLST on file for Resident 306. The MRA reviewed her resident list and Resident 306 had a zero marked by her name. The MRA stated a zero mark indicated a POLST was not completed for Resident 306. The MRA stated Resident 306 was admitted on [DATE]. The MRA stated a POLST was important in case Resident 306 had an emergency, such as not breathing. The MRA stated a POLST indicated to staff what the resident's code status (DNR - Do Not Resuscitate - a medical order written by a doctor to instruct health care providers NOT to do cardiopulmonary resuscitation [CPR - an emergency lifesaving procedure performed when breathing stops or the heart stops beating] if breathing stops or the heart stops beating) was. The MRA checked for a paper copy of Resident 306's POLST. The MRA stated Resident 306 did not have a POLST. The MRA stated Resident 306's POLST should have been discussed during admission. The MRA stated without a POLST, staff would perform a full code, including CPR, even if the resident was a DNR, which would go against the resident or family's wishes.
During an interview on [DATE] at 2:51 p.m. with the Assistant Director of Nursing (ADON), the ADON stated the POLST was important because it stated medical interventions for any changes in the resident's medical condition. The ADON stated staff needed to respect the wishes of the resident. The ADON stated the POLST gave resident's decisions for code status, nutrition, etc. The ADON stated staff was to honor the rights of the resident for any kind of life sustaining treatment in any kind of emergency. The ADON stated having an incomplete POLST for one month was not acceptable. The ADON stated her expectation was for all residents to have a completed POLST.
During a review of the facility's job description document titled, Health Information Manager, dated [DATE], the document indicated . monitors compliance of documentation via each of the clinical applications . follows [name of facility] auditing guidelines . provides required documentation needed triple-check .
During a review of the facility's policy and procedure (P&P) titled, admission Audit Best Practice Guidelines, undated, the P&P indicated, . objective . to ensure all admission health records are initiated and completed timely . it is the practice of this facility to audit all health records at 48 hours, 7 days, 14 days, 21 days, and at 30 days (if needed) . the Medical Records Department will initiate an admission audit within 72 hours of admission for each Resident entering the facility .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. During a concurrent observation and interview on 2/3/25 at 8:51 a.m. with Resident 505 in the resident's room, Resident 505 was sitting upright in bed wearing glasses, a dark blue sling cradled her right arm, and an oxygen nasal cannula and oxygen tubing were lying on the floor. Resident 505 was alert and oriented, able to state her name, date, location and was able to understand and answer questions. Resident 505 stated she did not use oxygen continuously and was not aware the tubing was on the ground.
During a record review of Resident 505's admission Record (AR), dated 2/6/25, the AR indicated, Resident 505 was admitted to the facility on [DATE] with diagnoses: fall with a left broken thigh bone surgically repaired with an artificial hip joint, uneven broken right collarbone, and difficulty breathing.
During a review of Resident 505's Minimum Data Set (MDS-a federally mandated resident assessment tool), dated 2/4/25, the MDS section C indicated, Resident 505 had a Brief Interview for Mental Status (BIMS-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 14, which indicated Resident 505 was cognitively intact (without intellectual disability).
During an interview on 2/3/25 at 09:01 a.m. with Certified Nurse Aide (CNA) 1 in Resident 505's room, CNA 1 stated the resident would decide when to use oxygen which was why the tubing was on the floor. CNA 1 stated the tubing should be kept in a bag and tied on the side of the oxygen concentrator (a medical device that extracts oxygen from air and filters it into a purer form for breathing) to keep it from getting contaminated and prevent the resident from getting an infection.
During a concurrent observation and interview on 2/3/25 at 09:10 a.m. with Registered Nurse (RN) 1 in Resident 505's room, RN 1 stated the resident had an order for oxygen as needed. RN 1 stated the oxygen nasal cannula and tubing should not be on the floor due to the risk of cross contamination and infection. Observed RN 1 pick up and discard the tubing from the floor and replaced with a sealed package.
During an interview on 2/5/25 at 10:29 a.m. with CNA 2 in a Resident 64's room, CNA 2 stated if a resident was on oxygen, the staff should ensure the tubing was properly placed in a plastic bag when not in use. CNA 2 stated if the oxygen tubing fell on the floor, staff should throw it away as the floor was dirty and germs could contaminate the tubing. CNA 2 stated if germs contaminated the tubing and was placed on the resident, it could put the resident at risk for infection.
During an interview on 2/5/25 at 11:33 a.m. with RN 1 at the nurse's station, RN 1 stated oxygen tubing and nasal cannula should be placed in a bag when not in use to prevent it from being on the floor. RN 1 stated tubing could become a ligature risk and if the tubing touched the floor, the tubing could become an infection control concern due to contamination.
During an interview on 2/5/25 at 2:25 p.m. with the Director of Nursing (DON) in the DON's office, the DON stated oxygen tubing and nasal cannula should be stored in a plastic bag that hung on the concentrator. The DON stated the facility would not be following policy if oxygen tubing or a nasal cannula was found on the floor as it could be a potential infection control risk.
During an interview on 2/6/25 at 1:31 p.m. with the Director of Infection Prevention (DIP) in the visitor lounge, the DIP stated the facility expected oxygen tubing and nasal cannula to be stored in clear plastic bags when not in use to prevent the risk of infection. The DIP stated if the oxygen tubing and nasal cannula were not stored properly and found on the ground, it may increase the risk of introducing germs to residents. The DIP stated when staff identified oxygen tubing had fallen on the floor, they were expected to dispose the dirty tubing and provide new tubing as part of infection prevention.
During a review of Resident 505's Order Summary, dated 2/10/25, the Order Summary indicated, Oxygen a 2 [liters per minute] via [nasal cannula] [as needed] for shortness of breath] .
During a review of Resident 505's Care Plan, date initiated 2/3/25, the Care Plan indicated, resident has low O2 saturation and SOB on exertion and intervention of oxygen therapy at 2 liters via nasal cannula as needed.
During a review of the facility's policy and procedure (P&P) titled, Oxygen Administration Per Nasal Cannula, dated 1/1/14, the P&P indicated oxygen tubing must be kept off the floor .
7. During a concurrent observation and interview on 02/04/25 at 3:02 p.m. with Licensed Vocational Nurse (LVN) 3 in Station 1, there was an opened container with tweezers, scissor, and scalpel inside the bottom drawer where other, unopened, supplies for wound treatment and changes were stored. LVN 3 stated, the container was a debridement tray and was opened. LVN 3 stated, he did not know if the tray had been used. LVN 3 stated, the open tray should not have been in the drawer. LVN 3 stated, any open supplies should have been thrown away. LVN 3 stated, sharps should have been properly discarded in the sharps disposal container (rigid puncture-resistant plastic or metal with leak-resistant sides and bottom, and a tight-fitting, puncture-resistant lid with an opening to accommodate depositing a sharp but not large enough for a hand to enter). LVN 3 stated, the open debridement container potentially was an infection control issue because the tray was no longer sterile.
During a concurrent observation and interview on 02/04/25 at 3:15 p.m. with LVN 5, LVN 5 stated she was the wound/treatment nurse (a nurse specializing in wound treatment) that day. LVN 5 stated, the open debridement tray was opened and should not have been in the drawer with the other unopened wound treatment supplies. LVN 5 stated, the open debridement tray should have been thrown out. LVN 5 stated, the opened debridement tray could have potentially posed an infection control issue if the instruments inside were used on the residents to clean their wounds.
During an interview on 02/05/25 at 11:40 a.m. with the Director of Infection Prevention (DIP), the DIP stated, the opened debridement tray that contained a tweezer, scissor, and scalpel should not have been stored in the drawer where other clean supplies were stored. The DIP stated, the debridement tray was no longer sterile since it was opened. The DIP stated, the debridement tray was used to debride (a medical removal of dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue) resident's wounds and was considered a sterile procedure. The DIP stated, any opened package was no longer considered sterile. The DIP stated, if the opened debridement tray was used on a resident, there was a potential for infection to develop if germs were introduced into a wound from the non-sterile instruments.
During an interview on 02/06/25 at 1:49 p.m. with the Assistant Director of Nursing (ADON), the ADON stated, the opened debridement tray should not have been in the drawer of the treatment cart with the other clean supplies. The ADON stated, the instruments in the opened debridement tray which included a tweezer, scissor, and scalpel should have been thrown away in the sharps container. The ADON stated, this was an infection control issue and had the potential for cross contamination (transfer of germs bacteria from item to another).
During a review of the facility's policy and procedure (P&P) titled, Storage and Expiration of Medications, Biologicals, Syringes and Needles, dated 2013, the P&P indicated, .Facility should ensure that .supplies are stored separately .and sterility conditions, according to the manufacturer's or supplier's recommendations .
During a review of the facility's P&P titled, Infection Prevention Manual For Long Term Care, dated 05/2024, the P&P indicated, .Sharps Precautions-safety engineered sharps should be used and used sharps should be placed in a appropriately labeled puncture resistant container .
8. During a concurrent observation and interview on 02/05/25 at 9:15 a.m. with the ADON in Station 1's utility supply room, staff's personal belongings were on top of the counter, in the sink, and next to a samples collection refrigerator. The ADON stated, there were seven liquid containers bottles, a backpack, a jacket, a cup in Station 1's utility supply room sink. The ADON stated, one re-usable liquid container bottle was next to a samples collection refrigerator where residents' urine, stool, and culture samples were stored, one re-usable liquid container bottle and a cup was in the sink, and the backpack, article of clothing, and one disposable water bottle, and four re-usable liquid containers were on top of the counter. The ADON stated, staff's personal items should not have been inside the utility supply room. The ADON stated, only clean supplies used for residents should have been stored inside.
During an interview on 02/06/25 at 11:40 a.m. with the DIP, the DIP stated, personal belongings should never have been stored inside the utility supply room. The DIP stated, personal belongings could potentially cause infections through cross contamination. The DIP stated, the utility supply room should only have clean supplies that were used for the residents. The DIP stated, the staff had designated lockers to put their personal belongings.
During an interview on 02/06/25 at 1:49 p.m. with the ADON, the ADON stated, staff personal belongings did not belong inside the utility supply room. The ADON stated, staff personal belongings were not sterile or clean and could have harbored germs and cross contaminated the clean supplies and caused infections to the residents. The ADON stated, the staff were given lockers in the employee breakrooms and a dedicated locker area to store their belongings. The ADON stated, no staff belongings should have been in any care area.
During a review of the facility's P&P titled, Infection Prevention Manual For Long Term Care dated 05/2024, the P&P indicated, .Standard Precautions .include a group of infection prevention practices that apply to all patients .in any setting which healthcare is delivered .these practices include .environmental cleaning and disinfection .Compliance Monitoring .The Infection Preventionist and facility management will establish the methods for compliance monitoring for infection prevention .each new employee providing direct resident care shall be observed during observation .Specific compliance issues will be discussed with the individual employee involved .
During a review of the professional reference (PR) titled, Storage of Clean and Sterile Supplies in Clinical Areas, found on https://www.albertahealthservices.ca/assets/healthinfo/ipc/hi-ipc-bpg-storage-clean-sterile.pdf dated 08/2023, the PR indicated, .Do not store items other than clean and sterile supplies in the area, e.g., clothing, staff personal belongings .
9. During a concurrent observation and interview on 02/05/25 at 9:20 a.m. with the ADON in Station 1 Medication Room, a syringe was found out of its package inside a cabinet where clean syringes were stored. The ADON stated, opened syringes should not have been stored with unopened syringes. The ADON stated, the opened syringe should have been discarded in the sharps disposal container. The ADON stated, opened syringes had the potential to cause infections through cross contamination. The ADON stated, opened syringes could have caused injury to nurses and could potentially cause an infection.
During an interview on 02/06/25 at 11:40 a.m. with the DIP, the DIP stated, any open syringes should have been thrown into the sharps disposal container. The DIP stated, an opened syringe was no longer sterile and if used on a resident, could have potentially introduced germs to a resident and cause an infection.
During an interview on 02/06/ at 1:49 p.m. with the ADON, the ADON stated, opened syringes should not have been inside the medication room cabinet and should have been disposed into an sharps disposal container. The ADON stated, the opened syringe was no longer sterile and if used on residents could potentially have caused infections through cross contamination.
During a review of the facility's P&P titled, Storage and Expiration of Medications, Biologicals, Syringes and Needles, dated 2013, the P&P indicated, .Facility should ensure that .supplies are stored separately .and sterility conditions, according to the manufacturer's or supplier's recommendations .
During a review of the facility's P&P titled, Infection Prevention Manual For Long Term Care, dated 05/2024, the P&P indicated, .Sharps Precautions-safety engineered sharps should be used and used sharps should be placed in a appropriately labeled puncture resistant container .Handling And/Or Disposing of Used Needles .Safety Precautions .After use .discard the needle into the sharps container .used needles and syringes must be placed in the sharps container .needles, used or unused, may not be discarded into trash receptacles .discard in sharps container .
Based on observation, interview, and record review, the facility failed to establish and maintain an effective infection prevention and control program for six of 17 sampled residents (Resident 34, 37, 152, 305, 306, and 505) when:
1. When Resident 34's handheld nebulizer mouthpiece (a piece of plastic that fits into a small, handheld machine that turns liquid medicine into a mist and resident inhale the mist through the mouthpiece for delivery of medication) was observed on top of the machine next to a urinal.
2. Resident 37's foley catheter (helps drain urine from your bladder) bag and tubing were on the ground.
3. Resident 152's urinal (a vessel used for receiving urine) containing urine was on top of Resident 152's bedside table with food, a glass of water, water pitcher and cell phone.
4. Enhanced Barrier Precautions (EBP- an infection control intervention designed to reduce transmission of resistant organisms [bacteria that have become resistant to certain antibiotics] that requires gown and glove use during high contact resident care activities) were not in place when licensed nurses provided wound care to Resident 152 and Resident 305's surgical wounds.
5. EBP were not followed by therapy staff when entering and performing Activities of Daily Living (ADL - the tasks of everyday life that include eating, dressing, getting into or out of a bed or chair, taking a bath or shower, and using the toilet) tasks with Resident 306.
6. Resident 505's nasal cannula (flexible tube with two prongs that fit inside the nostrils), and oxygen tubing (flexible tube connected to an oxygen source) were found on the floor.
7. An opened debridement tray (a sterile [free from germs]) medical kit containing necessary instruments used to remove dead, damaged, or infected bodily tissue to promote wound healing) containing a tweezer, scissor, and scalpel (a small straight thin-bladed knife used especially in surgery) was found on the bottom drawer of Station 1's treatment cart (a mobile cart with drawers stocked with supplies for wound care and dressing changes) where other unopened and clean wound dressing supplies were stored.
8. Staff's personal belongings including seven liquid container bottles, a backpack, piece of clothing (a jacket), and a cup were found inside Station 1's utility supplies room. One re-usable liquid container bottle was found next to a samples collection refrigerator where residents urine, stool, and culture samples were stored. One re-usable liquid container bottle and a cup was in the sink, and the backpack, article of clothing, and one disposable water bottle, and four re-usable liquid containers were on top of the counter.
9. An opened syringe outside its package was found in Station 1's medication room in a cabinet where clean, unopened syringes were stored.
These failures placed residents at risk for cross-contamination (the process when germs are unintentionally transferred from one substance or object to another, which causes a harmful effect) and infection (an invasion of the body by germs that cause disease).
Findings:
1. During a review of Resident 34 's admission Record (AR-a document with personal identifiable and medical information), dated 2/6/25, the AR indicated, Resident 34 was admitted to the facility on [DATE] with diagnoses which included pneumonia (inflammation (a protective response of the body to harmful stimuli, such as infections, injuries, or toxins) and fluid in your lungs caused by a bacterial, viral or fungal infection), myasthenia gravis (chronic neuromuscular disease that causes weakness in the voluntary muscles), chronic obstruction pulmonary disease (COPD- group of lung diseases that cause airflow obstruction and breathing problems), pleural effusion (condition where excess fluid accumulates in the area between the lungs and the chest wall), and pain.
During a review of Resident 34's Minimum Data Set (MDS-a functional and cognitive abilities assessment) assessment, dated 1/6/24, the MDS indicated the Brief Interview for Mental Status (BIMS) score was 15 out of 15 (a BIMS score of 13-15 indicates cognitively intact (having the ability to think, learn, and remember clearly )8-12 indicates moderately impaired and 0-7 indicates severe impairment), which indicated Resident 34 was cognitively intact.
During a concurrent observation and interview on 2/3/25 at 11:17 a.m. in Resident 34's room, a nebulizer (a small machine that turns liquid medicine into a mist that can be easily inhaled) and handheld mouthpiece w observed on top of the machine next to a urinal. Resident 34 stated he used the nebulizer for shortness of breath.
During a concurrent observation and interview on 2/3/25 at 2:18 p.m. with License Vocation nurse (LVN) 1, LVN 1 stated the handheld nebulizer mouthpiece should have been stored in a bag after each use. LVN 1 stated storing the handheld nebulizer mouthpiece in a bag was important to prevent cross contamination. LVN 1 stated Resident 34 was at risk for a respiratory infection when the handheld nebulizer mouthpiece was out on the table next to the urinal. LVN 1 stated nurses were responsible to store the nebulizer handheld mouthpiece away.
During an interview on 2/7/25 at 4:10 p.m. with the Director of Infection Prevention (DIP), the DIP stated the nebulizer handheld mouthpiece should have been stored in a bag when not in use. The DIP stated storing the nebulizer handheld mouthpiece in a bag could prevent cross contamination. The DIP stated Resident 34 was at risk for respiratory infections. The DIP stated all nursing department were responsible for storing the nebulizer handheld mouthpiece in the bag.
During an interview on 2/7/24 at 6:01 p.m. with the Director of Nursing (DON) the DON stated all nurses were expected to wash, dry, and put the nebulizer handheld mouthpiece in a clear plastic bag after each use. The DON stated the nebulizer handheld mouthpiece should have been in a clear plastic bag. The DON stated Resident 34 was at risk for respiratory infections from cross contamination. The DON stated all nurses and Infection Preventionists (IP) were responsible for ensuring the handheld nebulizer was stored correctly. The DON stated the nurses and IP did not follow the facility policy when the nebulizer handheld mouthpiece was not stored appropriately.
During a review of the facility's policy and procedure (P&P) titled, Nebulized Medication/Handheld Nebulizer, dated 9/2016, the P&P indicated, .9. Discard any residue of the medication, rinse the nebulizer and mouthpiece. Shake to air dry and store in a plastic bag that is labeled with the resident name and room number .
2. During a review of Resident 37's Face Sheet (a summary of important information regarding a patient which include patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 2/5/25, the Face Sheet indicated, Resident 37 was admitted to the facility on [DATE] with a diagnosis of cellulitis (a serious deep infection of the skin caused by bacteria) of the left lower limb, muscle weakness (loss of muscle strength), mild dementia (a brain condition that causes memory loss, thinking problems, and behavioral changes), neuromuscular dysfunction of the bladder (occurs when the nerves that control the bladder do not work properly) and peripheral vascular disease (a condition that occurs when blood vessels narrow or block, reducing blood flow to the arms and legs).
During a review of Resident 37's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive and physical function) assessment, dated 1/16/25, the MDS assessment indicated Resident 37's Brief Interview for Mental Status (BIMS -assessment of cognitive status for memory and judgment) assessment score was 15 out of 15 (a score of 13-15 indicates cognitively intact (a person is able to think clearly, remember things well, and make sound decisions, essentially having normal brain function with no significant problems with thinking, learning, or reasoning abilities), 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 37 was cognitively intact.
During a concurrent observation and interview on 2/4/25 at 9:15 a.m. with Resident 37, in Resident 37's room, Resident 37's foley catheter bag and tubing was set on the floor by Certified Nursing Assistant (CNA) 11 while adjusting her wheelchair. Resident 37 stated she was unaware the bag and tubing were on the floor.
During an interview on 2/6/25 at 10:27 a.m. with Registered Nurse (RN) 3, RN 3 stated she was the nurse for Resident 37. RN 3 stated Resident 37's catheter bag and tubing should never be on the floor. RN 3 stated this put the resident at risk for cross-contamination and the floor was a source of infection. RN 3 stated due to the resident's co-morbidities (when a person has more than one disease or condition at the same time) an infection for her could result in a hospitalization.
During an interview on 2/6/25 at 11:07 a.m. with the Director of Staff Development (DSD), the DSD stated the CNA should have cleaned the tubing and the catheter bag after it hit the floor. The DSD stated this issue was an infection problem.
During an interview on 2/7/25 at 2:15 p.m. with the Infection Preventionist (IP), the IP stated the tubing and catheter bag on the floor was an infection risk for Resident 37. The IP stated cross-contamination of bacteria could have occurred. The IP stated the CNA should have cleaned the bag and tubing with alcohol wipes. The IP stated the facility did not have a specific policy for staff to follow in terms of foley catheter maintenance and infection control.
During an interview on 2/7/25 at 4:35 p.m. with the Director of Nursing, the DON stated the catheter and tubing on the ground was a safety issue for Resident 37. The DON stated she could have developed an infection from the cross-contamination.
During a professional reference review from the Centers for Disease Control and Prevention (CDC) titled, Guideline for Prevention of Catheter-Associated Urinary Tract Infections 2009, dated 6/6/2019, (retrieved from https://www.cdc.gov/infection-control/media/pdfs/Guideline-CAUTI-H.pdf) the reference indicated, .Proper Techniques for Urinary Catheter Maintenance . 2. Keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor .
3. During a concurrent observation and interview on 2/03/25 at 4:20 p.m. with Resident 152 in Resident 152's room, Resident 152 was observed dressed, sleeping in bed with a left below the knee amputation (BKA - surgical removal of the portion of the leg below the knee). Resident 152 stated he had been at the facility for a couple weeks due to a left BKA. Observed a bandage wrapped on Resident 152's left leg. No bruising observed. Observed urinal on bed side table containing urine, with residents reading glasses, phone, cup of water, water pitcher and sandwich on bedside table.
During a review of Resident 152's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 2/6/25, the AR indicated Resident 152 was admitted to the facility from the acute care hospital on 1/17/25 with diagnoses of aftercare following surgical amputation (surgical removal of a body part), acquired absence of left leg below the knee, Type 2 Diabetes Mellitus (when the blood sugar levels in the body are too high), atrial fibrillation (an irregular heartbeat), peripheral vascular disease (the reduced circulation of blood to the arms or legs), Hepatitis B (an infection of the liver), and chronic obstructive pulmonary disease (COPD - a chronic lung disease causing difficulty in breathing).
During a review of Resident 152's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 1/20/25, the MDS section C indicated Resident 152 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive (involving the process of thinking, learning and understanding) understanding on a scale of 1-15 ) score of 15 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which indicated Resident 152 was cognitively intact.
During an interview on 2/05/25 at 10:13 with Certified Nursing Assistant (CNA) 16, CNA 16 stated it was not appropriate for a urinal to be on top of Resident 152's bed side table. CNA 16 stated a urinal on the bed side table was not adhering to Resident 152's dignity care plan and was not sanitary. CNA 16 stated the bedside table was where Resident 152 ate his meals. CNA 16 stated urine could have spilled on Resident 152's food and put Resident 152 at risk for infection. CNA 16 stated Resident 152 could have gotten sick.
During a review of the facility's job description document titled, Certified Nursing Assistant (CNA), dated 11/13/17, the document indicated, . provide restorative assistance and support to maintain resident ADL function as per the plan of care . provide the clinical and support services needed to meet all physical and psycho-social needs of the residents and patients . maintains privacy and dignity while providing care and services . ensures resident personal care products/items are stored at bedside appropriate and are labeled/bagged as necessary .
4. During a concurrent observation and interview on 2/03/25 at 8:32 a.m. with Resident 305 in Resident 305's room, Resident 305 was observed in bed, wearing a gown. Observed a urinary catheter (an indwelling urinary catheter - a thin tube placed in the bladder to drain urine into a bag) drainage bag hanging on the lower side of the bed without a dignity cover(a bag used to the cover and hold the catheter drainage and collection bag, so it was not visible). No EBP sign was observed placed by the doorway to Resident 305's room. Resident 305 stated he had been at the facility for four days for left BKA. Observed Resident 305's wound to left BKA unwrapped, lying on the bed sheet with sutures and staples visible. Resident 305 stated his bandage wrap fell off overnight, and staff did not put his bandage back on. Resident 305 stated his wound should have been wrapped with a dressing.
During a review of Resident 305's AR, dated 2/6/25, the AR indicated Resident 305 was admitted to the facility from the acute care hospital on [DATE], with a readmission on [DATE]. Resident 305's diagnoses consisted of aftercare following surgical amputation, acquired absence of left leg below the knee, type 2 Diabetes Mellitus, atrial fibrillation, peripheral vascular disease, and neuromuscular dysfunction of the bladder (when a person does not have bladder control because of brain, spinal cord or nerve problem).
During a review of Resident 305's MDS, dated 2/6/25, the MDS section C indicated Resident 305 had a BIMS score of 14, which indicated Resident 305 was cognitively intact.
During an interview on 2/05/25 at 11:02 a.m. with Licensed Vocational Nurse (LVN) 4, LVN 4 stated she already changed Resident 305's dressing. LVN 4 stated other nurses were able to perform dressing changes. LVN 4 stated Residents with surgical wounds were not on EBP precautions.
During an observation on 2/05/25 at 2:08 p.m. in Resident 152's room, no EBP sign was observed placed next to Resident 152's room. Observed Licensed Vocational Nurse (LVN) 4 perform a dressing change of Resident 152's left BKA. LVN 4 performed hand hygiene and donned gloves. LVN 4 asked Resident 152 of his pain level, explained the procedure to Resident 152 and proceeded to remove blood soiled gauze from Resident 152's wound without donning a gown. LVN 4 removed her gloves, performed hand hygiene, donned new gloves and irrigated Resident 152's wound without donning a gown.
5. During an observation on 2/03/25 at 10:01 a.m. in the hallway in front of Resident 306's room, Occupational Therapist (OT) 1 was observed entering Resident 306's room without donning a gown. An EBP sign was observed above Resident 306's name plate next to her door.
During an interview on 2/03/25 at 10:14 a.m. with OT 1, OT 1 stated she worked with Resident 306 on performing her ADLs and verified Resident 306 was safe to go home. OT 1 stated she helped Resident 306 with sitting up on the edge of her bed and helped Resident 306 perform personal hygiene. OT 1 stated she was not sure which resident was on EBP. OT 1 stated it was important to follow EBP practices and to wear a gown when working with EBP residents to prevent the spread of germs between patients. OT 1 stated she should have put a gown on before providing care to Resident 306. OT 1 stated she did not see the EBP sign.
During an interview on 2/03/25 at 10:18 a.m. with Resident 306 in Resident 306's room, Resident 306 was observed dressed in bed, with oxygen infusing via nasal cannula. Urinary catheter bag observed on the lower side of her bed with a dignity cover over the bag. Resident 306 stated she had been in the facility for five or six days due to inability to walk. Resident 306 stated she was taking antibiotics when she first came in and staff used to wear a gown when providing care.
During an interview on 2/05/25 at 10:13 a.m. with CNA 16, CNA 16 stated staff received Infection Prevention training with the Infection Preventionist (IP). CNA 16 stated staff received in-services regarding what PPE to wear for residents on EBP.
During an interview on 2/05/25 at 10:48 a.m. with the IP, the IP stated if a resident was on EBP, he would have put up a sign on the resident's door. The IP stated a resident would have met EBP criteria if they had an indwelling medical device, such as a catheter or chronic wound. The IP stated his understanding of a chronic wound was a wound present longer than 12 months. The IP stated stage III ulcers, or surgical sites did not require EBP precautions. The IP stated he gave training to staff two times a year, so staff would know what to do to keep residents safe. The IP stated staff training included Occ[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure corridors were equipped with firmly secured handrails on each side of the corridor.
This failure put residents at increased risk for falls when utilizing the handrail for assistance with walking.
Findings:
During an observation on 2/03/25 at 8:43 a.m. in the Station 2 Hallway, across from room [ROOM NUMBER], the handrail across the hall was observed to be broken and loose. The handrail next to room [ROOM NUMBER] on the west side of the doorway was observed to be missing a curved piece of wood exposing the metal bracket and screws.
During an interview on 2/05/25 at 10:34 a.m. with the Maintenance Supervisor (MS), the MS stated the facility used the TELS System to notify his department of any issues that needed repair. The MS stated any staff could access the system for repairs. The MS stated he was notified of broken handrails, and they were repaired right away. The MS stated the curved ends of the handrails were obsolete and the facility could not replace them. The MS stated residents used the handrails for walking with the Rehabilitation Nursing Assistant (RNA). The MS stated broken and loose handrails placed residents at risk for injury.
During a review of the facility's job description document titled, Supervisor, Maintenance, undated, the document indicated, . ensure timely and effective repairs to all systems, and equipment as required . ensure that all patient and resident rooms are properly maintained (furniture, wall covering, flooring, plumbing, lights, etc.) .
During a review of the facility's policy and procedure (P&P) titled, Safe, Clean, Comfortable, and Homelike Environment, dated 6/2023, the P&P indicated, . in accordance with residents' rights, the facility will strive to provide a safe, clean, comfortable and homelike environment . that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk . refers to any environment in the facility that is frequented by residents, including (but not limited to) the residents' rooms, hallways . therapy areas . housekeeping and maintenance services will be provided as necessary . promptly reporting issues to maintenance department, such as . broken or unsafe facility equipment . ED, DON, and/or Maintenance/Housekeeping Supervisor should conduct regular facility rounds and provide general monitoring/oversight of efforts to maintain a safe, clean, comfortable environment .
During a review of the facility's Maintenance Manual P&P titled, Scope of Services, dated 8/2014, the P&P indicated, .the Maintenance Department is responsible for the condition and function of the facility's physical plant, including all utilities, grounds, and equipment . all areas of the facility and equipment therein, are inspected and maintained in accordance with the TELS Preventive Maintenance Program .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure dignity was provided for two of 11 sampled residents (Resident 3, and 305) when:
1.
Resident 3's foley catheter (a soft, flexible tube inserted into the bladder to help drain urine into a bag) drainage bag was without a dignity bag (a bag used to the cover and hold the catheter drainage and collection bag so it is not visible), leaving the urine visible to anyone who walked into Resident 3's room
This failure resulted in Resident 3 not being provided his right to have a dignified existence while in the facility.
2.
Resident 305's foley catheter drainage bag was without a dignity bag.
This failure violated Resident 305's privacy and had the potential to affect the self-esteem, self-worth, and quality of life of Resident 305.
Findings:
1. During an observation on 2/3/25 at 9:57 a.m. in Resident 3's room, Residents 3 foley catheter bag was uncovered leaving the urine visible to anyone who entered the room.
During a concurrent observation and interview on 2/3/25 at 10:00 a.m. with Certified Nursing Assistant (CNA) 9, Resident 3's catheter bag was uncovered leaving the urine visible. CNA 9 stated the catheter bag needed to be covered it was the policy of the facility. CNA 9 stated providing a privacy bag for Resident 3's catheter ensured he was given dignity, and it was his right to have dignity. CNA 9 stated residents with catheters could feel vulnerable or embarrassed because it was not a common thing for people to have.
During an interview on 2/6/25 at 9:59 a.m. with CNA 10, CNA 10 stated Resident 3 should have had a privacy bag to cover his catheter. CNA 10 it was not dignified to leave Resident 3's catheter bag uncovered.
During an interview on 2/6/25 at 11:57 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 3 should have had a privacy bag placed on his catheter bag. LVN 1 stated a privacy bag provided dignity and privacy for Resident 3's medical condition. LVN 1 stated it was unacceptable for Resident 3 to have his catheter bag uncovered
During an interview on 2/7/25 at 3:43 a.m. with the Director of Nursing (DON), the DON stated Resident 3's right for dignity was violated as a result of not having a privacy bag over his catheter. The DON stated having the catheter bag uncovered did not provide dignity or follow the facility's policy.
During a review of the facility's policy and procedure (P&P) titled, Resident Rights, dated 10/22, indicated, . The resident has the right to a dignified existence . the resident has the right to be treated with respect and dignity .
2. During a concurrent observation and interview on 2/03/25 at 8:32 a.m. with Resident 305 in Resident 305's room, Resident 305 was observed lying in bed with head elevated, wearing a gown with left amputated (surgically removed) lower limb uncovered, and eating breakfast. Resident 305's catheter bag was observed hanging on the side of Resident 305's bed without a dignity cover. Resident 305 stated he did not know if his urinary bag was covered when he went out of his room.
During a review of Resident 305's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 2/6/25, the AR indicated Resident 305 was admitted to the facility from the acute care hospital on [DATE], with a readmission on [DATE]. Resident 305's diagnoses consisted of aftercare following surgical amputation (surgical removal of a body part), acquired absence of left leg below the knee, Type 2 Diabetes Mellitus (when the blood sugar levels in the body are too high), atrial fibrillation (an irregular heartbeat), peripheral vascular disease (the reduced circulation of blood to the arms or legs), and neuromuscular dysfunction of the bladder (when a person does not have bladder control because of brain, spinal cord or nerve problem).
During a review of Resident 305's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 2/6/25, the MDS section C indicated Resident 305 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive (involving the process of thinking, learning and understanding) understanding on a scale of 1-15 ) score of 14 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which indicated Resident 305 was cognitively intact.
During a concurrent observation and interview on 2/03/25 at 8:51 a.m. with CNA 13 in Resident 305's room, Resident 305's urinary catheter bag was observed without a dignity bag. CNA 13 stated Resident 305 should have had a privacy bag cover over his urinary catheter bag. CNA 13 stated the privacy bag cover was used to protect Resident 305's privacy and dignity.
During an interview on 2/06/25 at 10:13 a.m. with LVN 3, LVN 3 stated residents with urinary catheters should have had a dignity covering over their urinary bag. LVN 3 stated the dignity covering was for residents' privacy.
During a review of the facility's P&P titled, Dignity - Promoting/Maintaining Dignity, dated 10/2022, the P&P indicated, . staff members involved in providing care or interacting with residents must promote and maintain resident dignity . maintain resident privacy .
During a review of the facility's P&P titled, Resident Rights, dated 10/2022, the P&P indicated, . the resident has the right to a dignified existence . the resident has a right to be treated with respect and dignity .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of six sampled residents (Resident 556), were free of any significant medication errors when Resident 556's potassium chloride (a type of salt that gives the body potassium that gives the body minerals needed for the muscle and heart) 20MEQ (milliequivalent- a unit of measure) was not given according to manufacturer's instructions.
This failure had the potential to cause poor absorption of the medication (meaning the body could not use it properly) and stomach upset for Resident 556.
Findings:
During an observation on 02/04/25 at 9:25 a.m. in Resident 556's room, Resident 556 was awake and lying down in bed watching tv.
During a concurrent observation and interview on 02/04/25 at 9:56 a.m. with RN 1, Resident 556's potassium medication blister pack (a card that packages doses of medication within small, clear, or light-resistant amber-colored plastic bubbles [or blisters]) indicated, .Potassium CHL (chloride) 20MEQ TABLET .GIVE 1 TABLET BY MOUTH ONE TIME A DAY FOR SUPPLEMENT .Avoid lying down for at least 10 minutes after taking this medication .take this medication with a meal . RN 1 stated Resident 556 had breakfast around 7:30 a.m.
During a concurrent observation and interview on 02/04/25 at 10:13 a.m. with RN 1 and Resident 556 inside Resident 556's room, RN 1 administered Resident 556's scheduled potassium chloride 20MEQ. RN 1 stated, the potassium chloride was scheduled as a morning medication. RN 1 administered the potassium chloride while Resident 556 was in bed with a glass of water. Resident 556 laid back down in bed to watch tv. Resident 556 stated, he ate breakfast around 7:30 a.m.
During an interview on 02/04/25 at 11:21 a.m. with RN 1, RN 1 stated, she gave the potassium chloride at around 10:10 a.m. RN 1stated, she should have given the potassium chloride with a meal and kept Resident 556 up for at least 10 minutes after medication administration. RN 1 stated, she did not follow the manufacturer's guidelines printed on the medication blister pack. RN 1 stated, not following the manufacturer's guidelines could have potentially resulted in the medications were not absorbed by the body and would not have been effective.
During an interview on 02/06/25 at 1:10 p.m. with the Assistant Director of Nursing (ADON), the ADON stated, RN 1 did not follow the manufacturer's instructions on the medication blister pack. The ADON stated, nurses should have read all instructions before giving any medications to any resident. The ADON stated, it was important to read manufacturer's instructions to avoid any medication error. The ADON stated, not following the manufacturer's instructions could have potentially led to the potassium chloride to not be absorbed by the body and could have caused stomach upset. The ADON stated, it was important for Resident 556 avoid lying down at least 10 minutes after taking the potassium chloride to prevent any dysrhythmias (irregular heartbeat).
During a review of Resident 556's admission Record (AR), dated 02/06/25, the AR indicated, Resident 556 was admitted on [DATE] with a diagnosis of paroxysmal atrial fibrillation (a fast, irregular heartbeat that only lasts a few hours or days) and gastro-esophageal reflux disease without esophagitis (stomach acid repeatedly flows back up into the tube connecting the mouth and stomach).
During a review of Resident 556's Minimum Data Set Section C (MDSC - a resident assessment tool used to identify resident cognitive and physical function) assessment, dated 10/01/24, theMDS assessment indicated Resident 556's Brief Interview for Mental Status (BIMS -assessment of cognitive status for memory and judgment) assessment score was 15 out of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). A BIMS summary score of 15 indicated Resident 556 had an intact cognitive status (processes of thinking and reasoning) for memory and judgment.
During a review of Resident 556's Clinical Physician Orders (CPO), dated 02/04/25, the CPO indicated, .Potassium Chloride ER (extended release) Tablet Extended Release 20 MEQ .
During a review Resident 556's Medication admission Record (MAR), dated 02/01/25-02/28/25, the MAR indicated, .Tue [Tuesday] .4 .[signed] by RN 1 .Potassium Chloride ER Tablet Extended Release 20 MEQ .Give 1 tablet by mouth one time a day for supplement .
During a review of the facility's policy and procedure (P&P) titled, General Dose Preparation and Medication Administration, dated 12/01/07, the P&P indicated, .Facility staff should verify that the medication and name and dose are correct .
During a review of the professional reference (PR) titled, Medication Safety and Your Health, dated 11/18/24 found on https://www.cdc.gov/medication-safety/about/index.html , the PR indicated, .Medicines are safe when used as prescribed or as directed on the label .Take medicines as directed on the label .Some medicines should be taken with meals .Always .Read the label .Follow directions .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure license nurse perform residents assessment and document accurately according to the care provided when License Vocational Nurse (LVN 1) did not perform necessary assessment of her assigned residents and continued to document on Resident 1's clinical record Resident 1's vital signs, pain assessment, feeding tube assessment, enteral feeding intake, and provided non-pharmacological pain interventions care she did not provide from 12/25/21 to 12/30/21 during the time Resident 1 was admitted in general acute care hospital (GACH) from 12/25/21 to 12/30/21.
These failure resulted in an inaccurate Resident 1's clinical record which did not reflect Resident 1's current medical status and the lack of resident assessment could negatively impact the care of other residents residing in the facility.
Findings:
During a review of Resident 1's admission Record (a document containing demographic information), dated, [DATE] the admission Record indicated, Resident 1 was admitted to the facility on [DATE], with diagnoses that included Hemiplegia (paralysis in one side of the body) and Hemiparesis (partial paralysis) following unspecified Cerebrovascular Disease (a condition that affects the blood flow to the brain) affecting Right Non-Dominant side (Muscle weakness or partial paralysis on one side of the body). Type 2 Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). Morbid Obesity (a disorder that involves having too much body fat), Dysphagia (difficulty swallowing), Aphasia (disorder that makes it difficult to speak), Vascular Dementia (brain damage caused by multiple strokes), Sepsis (life-threatening blood infection), chronic kidney disease (kidneys stop filtering waste from your blood) .
During a review of Resident 1's SNF (Skilled Nursing Facility/NF (Nursing Facility) to Hospital Transfer Form, dated 12/25/21, the document indicated, .Resident 1 was sent to hospital on [DATE] at 2:26 p.m. for SOB (shortness of breath) via ambulance.
During a concurrent interview and record review on 11/26/24, at 11 a.m., with Assistant Director of Nursing (ADON), Resident 1's Weights and Vitals Summary dated 12/1/21-12/31/21 was reviewed. The Weights and Vitals Summary indicated, on 12/28/21 at 5:46 a.m. LVN 1 documented Resident 1's Blood Pressure 122/78, Temperature 98 degrees, Respiration 18 breaths per minute, Pulse 78 beats per minute, Pain Level was between 0-2 and Blood oxygen level was at 98%.
During a review of Resident 1's Medication Administration Record (MAR) dated 12/1/21-12/31/21. The MAR indicated, physician orders .Enteral Feed (a method of providing nutrition to the body through the stomach) Order every night shift Enteral-Change Syringe q [every] 24 hours . LVN 1 documented on the MAR on 12/29/21 and 12/30/21 the order was completed.
During a review of Resident 1's MAR dated 12/1/21-12/31/21. The MAR indicated, physician orders .Enteral Feed Order every night shift every other day Enteral-Change tubing Q48 hrs.(hours) with each bottle/bag change . LVN 1 documented on the MAR on 12/29/21 the order was completed.
During a review of Resident 1's MAR dated 12/1/21-12/31/2. The MAR indicated, physician orders .Enteral Feed Order every shift Enteral-Check Residuals before beginning a feeding administration. If Greater than 100 cc (unit of measure) HOLD feedings and Recheck in 1 HR [hour] if not resolved CALL MD . LVN 1 documented on the MAR on 12/29/21 and 12/30/21 the order was completed.
During a review of Resident 1's MAR dated 12/1/21-12/31/21. The MAR indicated, physician orders .Enteral Feed Order every shift Enteral-Check Tube Placement before Feeding, flush and Meds, Choose methods and document 0 for no issue or 1 for issue when using Gastric Residual Volume & visual methods Enter actual ph (measure of how acidic a solution is) reading when using ph method. Add progress notes prn (as needed) . LVN 1 documented on the MAR on 12/29/21 and 12/30/21 the order was completed.
During a review of Resident 1's MAR dated 12/1/21-12/31/21. The MAR indicated, physician orders .Enteral Feed Order every shift Enteral-Elevate Head of bed at least 30 degrees during feeding, any medication administration and 30-minutes after feeding . LVN 1 documented on the MAR on 12/29/21 and 12/30/21 the order was completed.
During a review of Resident 1's MAR dated 12/1/21-12/31/21. The MAR indicated, physician orders . Enteral Feed Order every shift Enteral-Medication Administration Flush-flush with minimum of 30 ml(milliliters) water before giving medications, flush with at least 5ml between medications, and flush with minimum of 30 ml after all medications given . LVN 1 documented on the MAR on 12/29/21 and 12/30/21 the order was completed.
During a review of Resident 1's MAR dated 12/1/21-12/31/21. The MAR physician orders .Enteral Feed Order every shift Monitor for tube feeding complications including nausea, vomiting, diarrhea, complications, GI (referring to stomach) discomfort abdomen discomfort, coughing, congestion, choking, SOB, cyanosis (bluish discoloration of skin, nails, lips), frothy sputum, and unusual restlessness . LVN 1 documented on the MAR on 12/29/21 and 12/30/21 the order was completed.
During a review of Resident 1's MAR dated 12/1/21-12/31/21. The MAR indicated, physician orders . Pain non-Rx [prescription], record any non-drug intervention used to prevent OR relieve Pain-Nondrug intervention . LVN 1 documented on the MAR on 12/29/21 and 12/30/21 the order was completed.
During a review of Resident 1's MAR dated 12/1/21-12/31/21. The MAR indicated, physician orders .Pain-Record Highest Level of Pain Every Shift. LVN 1 documented on the MAR on 12/29/21 and 12/30/21 Resident 1's pain level was 0 and the order was completed.
During a review of Resident 1's MAR dated 12/1/21-12/31/21. The MAR indicated, physician orders . Enteral Feed Order every 6 hours Enteral -Flush Tubing with Min 240 ml water Q 6 hrs [hours] . LVN 1 documented on the MAR on 12/28/21 and 12/30/21 the order was completed.
During an interview on 11/26/24 at 11:30 a.m., with the ADON, the ADON stated, the documentation on the MAR for Resident 1 was completed by LVN 1. The ADON stated, Resident 1 was not in the facility and was admitted at the GACH when LVN 1 documented on the MAR from 12/25/21 through 12/30/21. The ADON stated, LVN 1 also documented Resident 1's vital signs and care the provided while Resident 1 was admitted at the GACH. The ADON stated, it was unacceptable for LVN 1 to document services provided while Resident 1 was out of the facility. The ADON stated, it was illegal to document in a resident's medical record and falsify services and treatment were provided when it was not.
During an interview on 11/26/24 at 12:55 p.m., with the DON, the DON stated, LVN 1 documented in Resident 1's clinical record medical care and services provided while Resident 1 was at the GACH. The DON stated, LVN 1 did not follow the five rights of medication administration when LVN 1 documented in the MAR enteral feeding was administered to Resident while Resident 1 was not in the facility and was admitted at the GACH. The DON stated, this type of documentation could affect residents' safety and wellness. The DON stated, these was unacceptable and placed all residents on the facility at risk for their health and wellness.
During a telephone interview on 12/3/24 at 11:20 a.m., with LVN 1, LVN 1 stated, she was familiar with Resident 1 and was assigned to care for Resident 1. LVN 1 stated, her electronic signature on the MAR was LF 37. LVN 1 stated, when treatment was provided to residents there would be a check mark and LF37 on the MAR indicated she was the LVN who provided the treatment and care on the specific date. LVN 1 stated, she made a mistake on her documentation. LVN1 stated, she documented on Resident 1's clinical record, care and treatment was provided while Resident 1 was admitted in the GACH. LVN 1 stated, I am responsible because my signature is on the MAR. LVN1 stated, Documenting is a very important part of my job and I failed to accurately document for Resident 1.
During a review of the facility's Policy and Procedure (P&P) titled, General Dose Preparation and Medication Administration dated 12/01/07 the P&P indicated This Policy 6.0 sets forth the procedures relating to general dose preparation and medication administration. Facility staff should also refer to Facility policy regarding medication administration and should comply with Applicable Law and the State Operations Manual when administering medications . Verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident .
During a review of the facility's document titled Job Description/Performance Evaluation, dated 11/13/17, the job description indicated, job title LVN/LPN . provides accurate assessment, over-sight, and monitoring of patients for quality medical management and early detection of changes in condition . utilizes professional standards in performing basic assessment and clinical monitoring . implements and maintains established policies and procedures relative to skin care treatments . properly prepares and administers medications and treatments . complies with professional standards, policies & procedures . principles for administering medications, treatments .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide services which meet professional standards of practice for one of three sampled residents (Resident 1) when License Vocational Nurse (LVN 1) did not perform necessary assessment of her assigned residents and continued to document on Resident 1's clinical record Resident 1's vital signs, pain assessment, feeding tube assessment, enteral feeding intake, and provided non-pharmacological pain interventions care she did not provide from 12/25/21 to 12/30/21 during the time Resident 1 was admitted in general acute care hospital (GACH) from 12/25/21 to 12/30/21.
These failure resulted in an inaccurate Resident 1's clinical record which did not reflect Resident 1's current medical status and the lack of resident assessment could negatively impact the care of other residents residing in the facility.
Findings:
During a review of Resident 1's admission Record (a document containing demographic information), dated, [DATE] the admission Record indicated, Resident 1 was admitted to the facility on [DATE], with diagnoses that included Hemiplegia (paralysis in one side of the body) and Hemiparesis (partial paralysis) following unspecified Cerebrovascular Disease (a condition that affects the blood flow to the brain) affecting Right Non-Dominant side (Muscle weakness or partial paralysis on one side of the body). Type 2 Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). Morbid Obesity (a disorder that involves having too much body fat), Dysphagia (difficulty swallowing), Aphasia (disorder that makes it difficult to speak), Vascular Dementia (brain damage caused by multiple strokes), Sepsis (life-threatening blood infection), chronic kidney disease (kidneys stop filtering waste from your blood) .
During a review of Resident 1's SNF (Skilled Nursing Facility/NF (Nursing Facility) to Hospital Transfer Form, dated 12/25/21, the document indicated, .Resident 1 was sent to hospital on [DATE] at 2:26 p.m. for SOB (shortness of breath) via ambulance.
During a concurrent interview and record review on 11/26/24, at 11 a.m., with Assistant Director of Nursing (ADON), Resident 1's Weights and Vitals Summary dated 12/1/21-12/31/21 was reviewed. The Weights and Vitals Summary indicated, on 12/28/21 at 5:46 a.m. LVN 1 documented Resident 1's Blood Pressure 122/78, Temperature 98 degrees, Respiration 18 breaths per minute, Pulse 78 beats per minute, Pain Level was between 0-2 and Blood oxygen level was at 98%.
During a review of Resident 1's Medication Administration Record (MAR) dated 12/1/21-12/31/21. The MAR indicated, physician orders .Enteral Feed (a method of providing nutrition to the body through the stomach) Order every night shift Enteral-Change Syringe q [every] 24 hours . LVN 1 documented on the MAR on 12/29/21 and 12/30/21 the order was completed.
During a review of Resident 1's MAR dated 12/1/21-12/31/21. The MAR indicated, physician orders .Enteral Feed Order every night shift every other day Enteral-Change tubing Q48 hrs.(hours) with each bottle/bag change . LVN 1 documented on the MAR on 12/29/21 the order was completed.
During a review of Resident 1's MAR dated 12/1/21-12/31/2. The MAR indicated, physician orders .Enteral Feed Order every shift Enteral-Check Residuals before beginning a feeding administration. If Greater than 100 cc (unit of measure) HOLD feedings and Recheck in 1 HR [hour] if not resolved CALL MD . LVN 1 documented on the MAR on 12/29/21 and 12/30/21 the order was completed.
During a review of Resident 1's MAR dated 12/1/21-12/31/21. The MAR indicated, physician orders .Enteral Feed Order every shift Enteral-Check Tube Placement before Feeding, flush and Meds, Choose methods and document 0 for no issue or 1 for issue when using Gastric Residual Volume & visual methods Enter actual ph (measure of how acidic a solution is) reading when using ph method. Add progress notes prn (as needed) . LVN 1 documented on the MAR on 12/29/21 and 12/30/21 the order was completed.
During a review of Resident 1's MAR dated 12/1/21-12/31/21. The MAR indicated, physician orders .Enteral Feed Order every shift Enteral-Elevate Head of bed at least 30 degrees during feeding, any medication administration and 30-minutes after feeding . LVN 1 documented on the MAR on 12/29/21 and 12/30/21 the order was completed.
During a review of Resident 1's MAR dated 12/1/21-12/31/21. The MAR indicated, physician orders . Enteral Feed Order every shift Enteral-Medication Administration Flush-flush with minimum of 30 ml [milliliters-(unit of measurements)] water before giving medications, flush with at least 5 ml between medications, and flush with minimum of 30 ml after all medications given . LVN 1 documented on the MAR on 12/29/21 and 12/30/21 the order was completed.
During a review of Resident 1's MAR dated 12/1/21-12/31/21. The MAR physician orders .Enteral Feed Order every shift Monitor for tube feeding complications including nausea, vomiting, diarrhea, complications, GI (referring to stomach) discomfort abdomen discomfort, coughing, congestion, choking, SOB, cyanosis (bluish discoloration of skin, nails, lips), frothy sputum, and unusual restlessness . LVN 1 documented on the MAR on 12/29/21 and 12/30/21 the order was completed.
During a review of Resident 1's MAR dated 12/1/21-12/31/21. The MAR indicated, physician orders . Pain non-Rx [prescription], record any non-drug intervention used to prevent OR relieve Pain-Nondrug intervention . LVN 1 documented on the MAR on 12/29/21 and 12/30/21 the order was completed.
During a review of Resident 1's MAR dated 12/1/21-12/31/21. The MAR indicated, physician orders .Pain-Record Highest Level of Pain Every Shift. LVN 1 documented on the MAR on 12/29/21 and 12/30/21 Resident 1's pain level was 0 and the order was completed.
During a review of Resident 1's MAR dated 12/1/21-12/31/21. The MAR indicated, physician orders . Enteral Feed Order every 6 hours Enteral -Flush Tubing with 240 ml water Q 6 hrs [hours] . LVN 1 documented on the MAR on 12/28/21 and 12/30/21 the order was completed.
During an interview on 11/26/24 at 11:30 a.m., with the ADON, the ADON stated, the documentation on the MAR for Resident 1 was completed by LVN 1. The ADON stated, Resident 1 was not in the facility and was admitted at the GACH when LVN 1 documented on the MAR from 12/25/21 through 12/30/21. The ADON stated, LVN 1 also documented Resident 1's vital signs and care the provided while Resident 1 was admitted at the GACH. The ADON stated, it was unacceptable for LVN 1 to document services provided while Resident 1 was out of the facility. The ADON stated, it was illegal to document in a resident's medical record and falsify services and treatment were provided when it was not.
During an interview on 11/26/24 at 12:55 p.m., with the DON, the DON stated, LVN 1 documented in Resident 1's clinical record medical care and services provided while Resident 1 was at the GACH. The DON stated, LVN 1 did not follow the five rights of medication administration when LVN 1 documented in the MAR enteral feeding was administered to Resident while Resident 1 was not in the facility and was admitted at the GACH. The DON stated, this type of documentation could affect residents' safety and wellness. The DON stated, these was unacceptable and placed all residents on the facility at risk for their health and wellness.
During a telephone interview on 12/3/24 at 11:20 a.m., with LVN 1, LVN 1 stated, she was familiar with Resident 1 and was assigned to care for Resident 1. LVN 1 stated, her electronic signature on the MAR was LF 37. LVN 1 stated, when treatment was provided to residents there would be a check mark and LF37 on the MAR indicated she was the LVN who provided the treatment and care on the specific date. LVN 1 stated, she made a mistake on her documentation. LVN1 stated, she documented on Resident 1's clinical record, care and treatment was provided while Resident 1 was admitted in the GACH. LVN 1 stated, I am responsible because my signature is on the MAR. LVN1 stated, Documenting is a very important part of my job and I failed to accurately document for Resident 1.
During a review of the facility's Policy and Procedure (P&P) titled, General Dose Preparation and Medication Administration dated 12/01/07 the P&P indicated This Policy 6.0 sets forth the procedures relating to general dose preparation and medication administration. Facility staff should also refer to Facility policy regarding medication administration and should comply with Applicable Law and the State Operations Manual when administering medications . Verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident .
During a review of the facility's document titled Job Description/Performance Evaluation, dated 11/13/17, the job description indicated, job title LVN/LPN . provides accurate assessment, over-sight, and monitoring of patients for quality medical management and early detection of changes in condition . utilizes professional standards in performing basic assessment and clinical monitoring . implements and maintains established policies and procedures relative to skin care treatments . properly prepares and administers medications and treatments . complies with professional standards, policies & procedures . principles for administering medications, treatments
During a review of the professional reference from https://nursingeducation.org/insights/documentation/#:~:text=Principle%20of%20Confidentiality%20in%20Nursing,compliance%2C%20and%20following%20ethical%20guidelines titled Nurse Insights: What are the best practices for nursing documentation? dated 5/7/24, the professional reference indicated, Nursing documentation is an essential aspect of patient care and plays a pivotal role in enhancing communication between healthcare professionals, recording medical history accurately, and providing legal protection for registered nurses (RNs) . Importance of Accurate Nursing Documentation . Accurate nursing documentation significantly influences the quality of patient care. It not only provides a clear picture of the patient's medical history but also serves as a vital tool of communication among healthcare professionals. When filled accurately and systematically, it can also protect nurses legally if there's a complaint or lawsuit related to patient care . The Role in Patient Care Proper and precise nursing documentation forms the core of patient care. It documents the care plan and the patient's response to it. This includes medication administered, medical procedures performed, observations, and any significant changes in the patient's condition. Ineffective documentation could lead to medical errors or inappropriate care, which might harm the patient . Enhances Communication Among Healthcare Professionals . Documented nursing care enables a shared understanding of the patient's condition among all members of the healthcare team. It also aids in facilitating handovers between shifts, ensuring that all essential information is correctly relayed and continuity in patient care is maintained. Miscommunication or misunderstood information can put patient safety at risk . Legal Protection for Nurses . In the event of legal proceedings, the nursing documentation acts as tangible proof of the care provided and becomes a crucial part of the defense. Maintaining consistent, accurate, and factual narratives about patient care significantly bolsters a nurse's case in a court of law. Remember-all noted observations and actions have to be entered timely, concisely, and accurately. Follow your nursing program's guidelines and the legal and ethical requirements of your jurisdiction. Good documentation skills are integral to becoming a skilled and responsible nurse .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an effective pest control program as evidenced by presence of multiple dead cockroaches in the kitchen ' s floor beneath the food preparation area, the three-compartment sink, and on the floor behind the two-hallway ice machine.
These failures had the potential to cause foodborne illnesses (illness caused by food contaminated with bacteria, viruses, and parasites) in a medically vulnerable resident population who consumed food prepared in the kitchen.
Findings:
During an interview on 10/4/24 at 8:05 a.m., with the Ombudsman, the Ombudsman stated on 7/2024 during her visit at the facility she saw a live cockroach in a resident room. The Ombudsman stated she took a photograph of the cockroach and showed it to the Administrator.
During an interview on 10/4/24 at 9:43 a.m., with the Housekeeping Staff (HS) 1, HS 1 stated she was aware of the cockroaches in the facility.
During an interview on 10/4/24 at 10 a.m., with HS 2, HS 2 stated there was a problem with cockroaches in the facility.
During an observation on 10/4/24 at 11:20 a.m., at the hallway ice machine area near room [ROOM NUMBER], there were multiple dead cockroaches, debris on the floor behind the hallway ice machines.
During a concurrent observation and interview on 10/4/24 at 11:30 a.m., in the kitchen with Dietary [NAME] (DC), the DC validated the presence of two dead cockroach under the food preparation table, one dead cockroach underneath the three-compartment sink, one dead cockroach caught in a web near the ceiling by the dishwasher. The DC stated, It is important to keep everything clean.
During a concurrent observation and interview on 10/4/24 at 11:50 a.m., in the kitchen and pantry with Dietary Manager (DM), the DM validated the presence of cockroaches in the facility kitchen, and multiple dead cockroaches in the kitchen ' s floor beneath the food preparation area, three compartment sink, and two hallway ice machines. The DM stated it was important to keep the kitchen and pantry areas clean and we did not.
During a review of a document from the facility ' s pest control company titled, Orkin Invoice/Service Ticket (OIST), dated 8/7/24, the OIST indicated, General Comments: Treated kitchen area using a roach gel bait. Staff is saying the roach problem is now moving into the pantry area. I believe we will need to set up a service to spray the kitchen at a future date. Treated room [ROOM NUMBER] for American roaches using a roach gel bait. What I can recommend: Keeping all areas clean and clean of food debris and grease build up will go a long way toward cutting roach populations. Observations: Activity-Live; Pest Type: Cockroaches; Recommendation: Treatment rendered.
During a review of the OIST dated 8/28/24, the OIST indicated, General Comment: treated hallway ice machine and sink area using a roach gel bait including the kitchen area and pantry. Observations: Activity-Live; Pest Type: Cockroaches; Recommendation: Treatment rendered.
During a review of the Food and Drug Administration ' s Food Code, dated 2022, the Food Code indicated, 6-202.15. outer openings of a FOOD ESTABLISHMENT shall be protected against the entry of insects and rodents by:
(1) Filling or closing holes and other gaps along floors, walls, and ceilings.
The Food Code indicated, 6-501.111 Controlling Pests. The PREMISES shall be maintained free of insects, rodents, and other pests. The presence of insects, rodents, and other pests shall be controlled to eliminate their presence on the PREMISES by:
(A) Routinely inspecting incoming shipments of FOOD and supplies;
(B) Routinely inspecting the PREMISES for evidence of pests;
(C) Using methods, if pests are found, such as trapping devices or other means of pest control.
(D) Eliminating harborage conditions.
The Food Code indicated, 6-501.112 Removing Dead or Trapped Birds, Insects, Rodents, and Other Pests. Dead or trapped birds, insects, rodents, and other pests shall be removed from control devices and the PREMISES at a frequency that prevents their accumulation, decomposition, or the attraction of pests.

Based on observation, interview, and record review, the facility failed to ensure sanitary conditions was maintain in the kitchen when:
1. [NAME] to golden-colored buildup behind the stove and floor behind the stove had accumulation of debris.
2. The floor in the corner next to water inlet, behind the ice machine, between the pantry and kitchen had soiled napkins, straw, beverage cup, wrapper, and food debris.
3. The pantry floor had dark granular substance and a dark glob (a round clump of soft substance or thick liquid).
4. The floor underneath the pantry wire storage rack had scattered debris such as utensils, jelly cups, brown paper bag, napkins, hairnet, and saltine crackers in plastic wrap.
5. In the pantry a one-foot length of vinyl base board molding peeled off and was on the floor.
6. The pantry storage counter holding a five-gallon water jugs had black substance buildup.
7. Two dead cockroach observed under the food preparation table, one dead cockroach beneath the three compartment sink area, and one dead cockroach caught in a web near the ceiling by the dishwasher.
These failures had the potential to cause food borne illness (illness caused by food contaminated with bacteria, viruses, and parasites) to a highly susceptible population of residents who received food from the kitchen.
Findings:
During a concurrent observation and interview on 10/4/24 at 11:30 a.m., in the kitchen with Dietary [NAME] (DC), the DC validated the presence of:
1. [NAME] to golden-colored buildup behind the stove and floor behind the stove had accumulation of debris.
2. The floor in the corner next to water inlet, behind the ice machine, between the pantry and kitchen had soiled napkins, straw, beverage cup, wrapper, and food debris.
3. The pantry floor had dark granular substance and a dark glob (a round clump of soft substance or thick liquid).
4. The floor underneath the pantry wire storage rack had scattered debris such as utensils, jelly cups, brown paper bag, napkins, hairnet, and saltine crackers in plastic wrap.
5. In the pantry a one-foot length of vinyl base board molding peeled off and was on the floor.
6. The pantry storage counter holding a five-gallon water jugs had black substance buildup.
7. Two dead cockroach observed under the food preparation table, one dead cockroach beneath the three compartment sink area, and one dead cockroach caught in a web near the ceiling by the dishwasher.
The DC stated, It is important to keep everything clean.
During a concurrent observation and interview on 10/4/24 at 11:50 a.m., in the kitchen and pantry with Dietary Manager (DM), the DM validated the presence the brown to golden substance behind the stove, the dark substance buildup on the pantry floor, and the pantry storage counter, and accumulation of debris on the floor behind the stove, near the water inlet, the floor behind the ice machine, and the floor underneath the pantry wire storage rack. The DM stated it was important to keep the kitchen and pantry areas clean and we did not. The DM stated, We will clean it.
During a review of the facility ' s Employee Handbook, dated 8/20/21, the Employee Handbook indicated, All employees are expected to keep their work areas clean and organized.
During a review of the Food and Drug Administration ' s Food Code, dated 2022, the Food Code indicated, 6-501.12. PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean.
The Food Code indicated, 6-501.111 Controlling Pests. The PREMISES shall be maintained free of insects, rodents, and other pests. The presence of insects, rodents, and other pests shall be controlled to eliminate their presence on the PREMISES by:
(A) Routinely inspecting incoming shipments of FOOD and supplies;
(B) Routinely inspecting the PREMISES for evidence of pests;
(C) Using methods, if pests are found, such as trapping devices or other means of pest control.
(D) Eliminating harborage conditions.
The Food Code indicated, 6-501.112 Removing Dead or Trapped Birds, Insects, Rodents, and Other Pests. Dead or trapped birds, insects, rodents, and other pests shall be removed from control devices and the PREMISES at a frequency that prevents their accumulation, decomposition, or the attraction of pests.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of three residents (Resident 1) did not develop pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) when Resident 1 was assessed as a moderate risk for developing pressure ulcers and the nursing care plan of daily and weekly skin assessments was not implemented from 1/6/24 to 1/19/24 for early recognition of skin changes and implementation of appropriate interventions to prevent pressure ulcer.
These failures resulted in Resident 1 to develop a preventable Stage 3 (full thickness skin loss involving damage or death of the deepest layer of the skin that may extend down to, but not through, underlying connective tissues) pressure ulcer to the sacrum (located at the bottom of the spine, near the tail bone or coccyx) area.
Findings:
During a review of the clinical record for Resident 1, the admission Record (record containing resident demographic information), undated, the admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included Acute Respiratory Failure (a serious condition that makes it difficult to breathe), Generalized Muscle Weakness, Hypertension (high blood pressure), Mild Cognitive Impairment (decline in memory and thinking), Pneumonia (lung infection caused by bacteria), and Morbid Obesity (a complex disease involving appetite regulation and energy consumption).
During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool used to identify resident mental and physical functional level) assessment dated [DATE], the MDS indicated Resident 1's Brief Interview for Mental Status (BIMS-assessment of cognitive status for memory and judgement) assessment score of 9 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderate impairment, and 00-07 indicates severe impairment) indicating Resident 1 had moderate cognitive deficits.
During a review of the facility policy and procedure (P&P) titled Skin Integrity dated 8/1/14, the P&P indicated, . Residents identified to be at risk for skin breakdown (pressure ulcers) will have a routine assessment and interdisciplinary (IDT) care plan process implemented to maintain and/or improve skin integrity . 2. New admission residents will have a skin assessment on admission then weekly for three weeks . 4. Communication by Certified Nurse Assistant (CNA) to licensed nurse utilizing a skin condition worksheet or comparable document . 15. Weekly head to toe assessment will be completed of all residents by a Licensed nurse .
During a phone interview on 2/2/24, at 1:00 p.m., with General Acute Care Medical Social Worker (MSW), MSW stated she filed a complaint to the local Ombudsman (advocates for nursing home residents) office and the California Department of Public Health (CDPH, a government agency for the State of California in charge of protecting the public's health and helping shape positive health outcomes for individuals, families and communities) on 1/29/24 regarding Resident 1's facility-acquired pressure ulcer. MSW stated Resident 1 was transferred to Skilled Nursing Facility (SNF, a place where trained nurses in a medical setting are providing care to patients to continue recovering after an illness, injury or surgery) on 1/6/24 for rehabilitation and with no pressure ulcers or open skin. MSW stated Resident 1 was re-admitted to acute hospital on 1/25/24 due to abnormal vital signs (clinical data, such as pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions) and with stage 3 pressure ulcer to her sacrum area. MSW stated she was concerned about the quality of care being provided by the facility to its residents.
During a phone interview on 2/4/24, at 11:14 a.m., with Certified Nurse Aide (CNA) 1, CNA 1 stated he was the assigned CNA to care for Resident 1 on 1/19/24, from 3:00 p.m. to 11:30 p.m. CNA 1 stated, I'm a new CNA and it was my first time to work in that nursing unit and to care for [Resident 1]. She does not move much. She stayed in her bed for the duration of my shift. She has a urinary catheter [a flexible tube used to empty the bladder and collect urine in a drainage bag]. CNA 1 stated at approximately 9:00 p.m., he went to Resident 1's room to check and change her disposable brief. CNA 1 stated, She [Resident 1] had a bowel movement and while doing peri-care, I noticed an open area to her sacrum area. I immediately reported it to [RN 1]. The nurse came to the room and I assisted her [RN 1] by holding [Resident 1]'s back while she's assessing and measuring the wound. CNA 1 stated he does not recall receiving a report from the morning CNA regarding [Resident 1] having a pressure ulcer on her sacrum area. CNA 1 stated the task of checking Resident 1's skin was not listed on her care plan. CNA 1 stated he was not aware of the care plan intervention of assessing Resident 1's skin twice a day.
During a concurrent interview and record review on 2/5/24, at 7:25 p.m., with Registered Nurse (RN) 1, RN 1 stated she was the license nurse assigned to care for Resident 1 on 1/6/24. Resident 1's admission Note (AN), dated 1/6/24 was reviewed. The AN indicated, . 18:41 [6:41 p.m.] . 14. Skin note: Rash to perianal area [area between the genitals and anus], laceration [cut] to left medial [towards the middle] high, bruises to right dorsum [back] hand, swelling to left lateral malleolus [bone located at the ankle], swelling to right medial malleolus . RN 1 stated she was unable to find a documentation of Resident 1 having pressure ulcer to her sacrum area on admission.
During a concurrent interview and record review on 2/5/24, at 7:39 p.m., with RN 1, Resident 1's Nursing Progress Note (NPN) and Change in Condition Report (COC), dated 1/19/24 were reviewed. RN 1 stated she was the assigned RN to care for Resident 1 on 1/19/24, from 3:00 p.m. to 11:30 p.m. The NPN indicated, . 22:19 [10:19 p.m.] . CNA informed the writer that resident has [pressure] ulcer on her back. Writer went into the room and assessed the resident . The COC indicated, . 22:29 [10:29 p.m.] . pressure injury on sacrum, and three to five small bones fuse to create the coccyx] . this start on: 01/19/2024 . RN 1 stated she provided nursing care to Resident 1 since admission, and she was not aware of Resident 1 having a pressure ulcer to her sacrum area. RN 1 stated the morning nurse did not mention Resident 1 having a pressure ulcer to her sacrum area during change of shift report.
During a concurrent interview and record review on 2/5/24, at 7:46 p.m., with RN 1, Resident 1's Skin and Wound Evaluation, dated 1/20/24 was reviewed. The evaluation indicated, . 01:38 [1:38 a.m.] . Type: Pressure . Stage: Stage 3: Full-thickness skin loss . Location: Sacrum, Medical . Exact Date: 01/19/2024 . Wound Measurements: Area 36.4 cm (centimeter, unit of measurement) . Length 8.5 cm . Width 5.9 cm . RN 1 stated Resident 1's sacrum pressure ulcer was first discovered on 1/19/23 by [CNA 1]. RN 1 stated a stage 3 pressure ulcer was impossible to develop within a couple of hours. RN 1 stated Resident 1's skin was not assessed daily and should have been assessed.
During a concurrent interview and record review on 2/5/24, at 7:52 p.m., with RN 1, Resident 1's Nursing Care Plan (CP), dated 1/7/24 was reviewed. The CP indicated, . Focus: Potential for impaired skin integrity related to impaired mobility . Interventions . Observe skin integrity during am/pm [morning/afternoon] care . Date Initiated: 1/6/24 . Evaluate Skin Weekly . Date Initiated: 1/6/24 . RN 1 stated she was unable to find documentation a skin assessment was done during morning and afternoon care from 1/7/24 to 1/19/24. RN 1 stated she was unable to find documentation of weekly skin assessment from 1/7/24 to 1/19/24. RN 1 stated the facility failed to assess Resident 1's skin integrity twice a day and weekly which resulted to the late recognition of a stage 3 pressure ulcer to her sacrum area.
During a concurrent interview and record review on 2/6/24, at 10:45 a.m., with the Nursing Supervisor/Assistant Director of Nursing (ADON) 1, Resident 1's Nursing Care Plan (CP), dated 1/7/24 was reviewed. ADON 1 stated she was unable to find documentation a skin assessment was done during morning and afternoon care from 1/7/24 to 1/19/24. ADON 1 stated she was unable to find documentation of weekly skin assessment from 1/7/24 to 1/19/24. ADON 1 stated CNAs and licensed nurses were expected to implement Resident 1's skin integrity care plan and it was not done.
During a concurrent interview and record review on 2/6/24, at 10:51 a.m., with the ADON 2, Resident 1's CNA Task Description, undated was reviewed. The document indicated, . Task List . Roll Left & [and] Right every shift . Sit to Lying every shift . ADON 2 stated she was unable to find a specific task to check Resident 1's skin during morning and afternoon care. ADON 2 stated the facility failed to implement Resident 1's skin integrity care plan and did not assess Resident 1's skin twice a day and weekly which resulted to stage 3 pressure ulcer to her sacrum area. ADON 2 stated she and [ADON 1] were the designated clinical leaders for RNs, License Vocational Nurse (LVNs) and CNAs. ADON 2 stated she and [ADON 1] failed to ensure clinical staff were implementing Resident 1's skin integrity care plan.
During an interview on 2/6/24, at 11:46 a.m., with the Director of Nursing (DON), the DON stated Resident 1's nursing care plan interventions to prevent skin breakdown should have been implemented on admission and it was not done. The DON stated the facility failed to follow the P&P on Skin Integrity which contributed to Resident 1's development of stage 3 sacrum pressure ulcer.
During a review of Resident 1's clinical record titled, BRADEN SCALE FOR PREDICTING PRESSURE SORE RISK, dated 1/6/24, at 6:44 p.m., the document indicated, . 3. ACTIVITY . Bedfast: Confined to bed . 4. MOBILITY . Very Limited. Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently . 6. FRICTION & [and] SHEAR . Problem: Requires moderate to maximum assistance in moving . Score 13 . [AT RISK 15-18, MODERATE RISK 13-14, HIGH RISK 10-12, VERY HIGH RISK 9 or below] .
During a review of the facility policy and procedure (P&P) titled Prevention of Pressure Ulcer undated, the P&P indicated, . BASIC RESPONSIBILITY: Licensed Nurse and Nursing Assistant . 20. Asses for risk of pressure ulcer development . 28. Establish a turning and positioning schedule in bed and chair to meet the resident's needs . Documentation may include . Preventive measures used . Condition of the resident's skin . Goal: List MEASURABLE goal(s) to be accomplished .
During a review of the facility's document titled, Job Description . Certified Nursing Assistant (CNA), undated, the document indicated, . Maintain and use current, appropriate clinical knowledge of all required nursing policies and procedures . Provide the clinical and support services needed to meet all physical and psychosocial needs of the residents . Improve and maintain skin integrity and general health and comfort including: Provides skin care interventions as per the plan of care .
During a review of the facility's document titled, Job Description . Registered Nurse (RN), undated, the document indicated, . The primary purpose of this position is to function as a collaborative member of the IDT, provide patient quality care, optimal clinical outcomes . Utilizes professional standards in performing assessment and monitoring in accordance with scope of licensure . Develops, implements, evaluates, and updates plans of care accordingly . During a review of the facility's document titled, Job Description . Nursing Supervisor, undated, the document indicated, . The primary purpose of this position is to manage nursing department services on a day-to-day basis to achieve the identified clinical and operational results and assuring resident safety . Conduct clinical assessments; use critical thinking and coordinate professional standards of care . Develop, review, and revise care plans to accurately reflect Resident needs . Supervise nursing staff to maximize clinical outcomes and operations effectives . During a review of professional reference document titled Pressure Injury Prevention Points dated 2016, retrieved from https://npuap.org/page/PreventionPoints, the document indicated, Consider bedfast and chairfast individuals to be at risk for development of pressure injury . Develop a plan of care based on the areas of risk, rather than on the total risk assessment score. For example, if the risk stems from immobility, address turning, repositioning and the support surface . Inspect the skin at least daily for signs of pressure injury . Assess pressure points, such as the sacrum, coccyx, buttocks . Turn and reposition all individuals at risk for pressure injury . Continue to reposition an individual when placed on any support surfaces . Use a pressure redistributing chair cushion for individuals sitting in chairs or wheelchairs . Reposition weak or immobile .

2. A review of Resident #208's admission Record indicated the facility admitted the resident on 11/19/2023, with diagnoses that included acute respiratory failure with hypoxia and obstructive sleep apnea.
Review of Resident #208's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/21/2023, revealed Resident #208 resident received oxygen.
Review of Resident #208's care plan, initiated 11/21/2023 revealed the resident had oxygen therapy related to acute respiratory failure. Interventions indicated the resident received continuous oxygen at a rate of two liters per minute.
Review of Resident #208's Order Summary Report, with active orders as of 11/29/2023, revealed an order dated 11/21/2023, for continuous oxygen at two liters per minute by way of nasal canula for acute respiratory failure with hypoxia.
On 11/29/2023 at 8:30 AM, the surveyor observed Resident #208 receiving oxygen by way of a nasal canula with the oxygen concentrator set at three liters per minute.
During a concurrent observation and interview on 11/29/2023 at 9:19 AM, Registered Nurse (RN) #1 stated Resident #208 was ordered to receive oxygen at two liters per minute. RN #1 observed the resident's oxygen flow rate and adjusted to the ordered three liters per minute.
During an interview on 11/30/2023 at 11:50 AM, Assistant Director of Nursing #11 stated she expected oxygen to be delivered at the ordered flow rate.
During an interview on 11/30/2023 at 12:46 PM, the Executive Director stated he expected the nurses to administer oxygen according to the physician orders.
3. Review of Resident #106's admission Record revealed the facility admitted the resident on 11/02/2023, with a diagnosis to include chronic obstructive pulmonary disease (COPD).
Review of Resident #10's care plan, initiated on 11/03/2023, revealed the resident had diagnoses of emphysema/COPD related to exposure to industrial pollutants. Interventions directed the staff to administer oxygen as ordered.
Review of Resident # 106's Order Summary Report, with active orders as of 11/29/2023, revealed an order dated 11/21/2023, for oxygen at two liters per minute as needed for COPD.
On 11/29/2023 at 9:05 AM, the surveyor observed Resident #106 receiving oxygen by way of nasal canula at one and a half liter per minute.
During a concurrent observation and interview on 11/29/2023 at 9:11 AM, Licensed Vocational Nurse (LVN) #2 confirmed Resident #106's oxygen flow rate was set at one and a half liters per minute.
In an interview on 11/30/2023 at 11:51 AM, Assistant Director of Nursing #11 stated she expected the staff to follow the physician orders regarding oxygen therapy.
In an interview on 11/30/2023 at 12:28 PM, the Executive Director stated he expected staff to follow the physician's order.
Based on observations, interviews, record reviews, and policy review, the facility failed to ensure 1 (Resident #10) of 5 sampled residents reviewed for respiratory care had an order to receive oxygen. The facility further failed to ensure 2 (Resident #106 and Resident #208) of 5 sampled residents received oxygen at the flow rate ordered by the physician.
Findings included:
Review of a facility policy titled, Oxygen Administration, dated August 2014, revealed, Purpose To administer oxygen to the resident with insufficient oxygen is being carried by the blood to the tissues. The policy specified, e. Set the flow meter to the rate ordered by the physician.
1. Review of Resident #10's admission Record revealed the facility admitted Resident #10 on 11/02/2023, with diagnoses that included chronic obstructive pulmonary disease (COPD) and congestive heart failure.
Review of Resident #10's care plan initiated on 11/03/2023, revealed the resident had diagnoses of emphysema/COPD related to exposure to industrial pollutants. Interventions directed the staff to administer oxygen as ordered.
A review of Resident #10's Order Summary Report, with active orders as of 11/27/2023, revealed no order for oxygen.
A review of Resident #10's Progress Notes for the time period 11/03/2023 through 11/28/2023, revealed staff documented the resident received oxygen by way of a nasal canula.
On 11/27/2023 at 11:25 AM, the surveyor observed Resident #10 in bed. The resident's oxygen concentrator was set to deliver oxygen at three liters per minute.
On 11/28/2023 at 1:04 PM, the surveyor observed Resident #10 receiving oxygen at three liters per minute.
During an interview on 11/28/2023 at 1:05 PM, Certified Nursing Assistant (CNA) #7 stated Resident #10 had always worn oxygen.
During an interview on 11/28/2023 at 1:14 PM, CNA #12 stated Resident #10 had always worn oxygen.
During a concurrent observation and interview on 11/28/2023 at 3:42 PM, Licensed Vocational Nurse (LVN) #10 stated Resident #10 did not have a physician's order for oxygen until 11/28/2023. LVN #10 stated the resident should have had a physician's order for oxygen.
During an interview on 11/29/2023 at 9:49 AM, Assistant Director of Nursing (ADON) #9 acknowledged she called the physician on 11/28/2023 and got an oxygen order for Resident #10 to receive oxygen. ADON #9 stated the resident should have had an order for oxygen prior to 11/28/2023.

Based on observations, interviews, record review, and policy review, the facility failed to assess a resident prior to self-administration of medication for 1 (Resident #114) of 28 sampled residents.
Findings included:
Review of a facility undated policy titled, Self-Administration of Medication, revealed, 2. If the resident expresses a desire to self-administer their medications, or a physician orders self-administration, the facility will not allow the resident to self- administer meds [medications] until the following procedures are done: a. A Licensed Nurse will complete the Self-Administration Assessment Review which includes the resident's physical and cognitive ability to safely administer and store their medication(s).
Review of Resident #114's admission Record, revealed the facility admitted the resident on 09/11/2023 with diagnoses that included wedge compression fracture of thoracic 11 and thoracic 12 vertebra, spondylosis of the lumbar region, intervertebral disc degeneration of the lumbar region, and abnormalities of gait and mobility.
Review of Resident #114's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/20/2023, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact.
Review of Resident #114's care plan, initiated on 09/11/2023, revealed the resident had chronic pain related to malaise. Interventions directed the nursing staff to administer analgesia as ordered.
Review of Resident #114's Order Summary Report with active orders as of 11/28/2023, revealed an order dated 11/10/2023, for diclofenac sodium external gel 1% apply topically to joints three times a day for joint pain.
On 11/28/2023 at 9:09 AM, Resident #114 informed the surveyor they were given a small cup of topical cream (diclofenac sodium) for pain. Resident #114 then removed the small cup from the top shelf of their dresser drawer that was located next to the resident's bed.
On 11/28/2023 at 1:20 PM, Resident #114 stated they had received a new tube of diclofenac sodium from Licensed Vocational Nurse (LVN) #8. Resident #114 showed the surveyor the medication that was in a zipped pouch.
In an interview on 11/28/2023 at 2:17 PM, Certified Nursing Assistant #17 stated Resident #114 was not allowed to self-administer their medications.
In an interview on 11/28/2023 at 2:25 PM, LVN #18 acknowledged she gave Resident #114 a tube of diclofenac sodium.
During an interview on 11/30/2023 at 11:51 AM, Assistant Director of Nursing #11 stated the expectation was that if a resident had not been assessed to self-administer medication, the resident should not have the medication in their possession.
During an interview on 11/30/2023 at 12:28 PM, the Executive Director (ED) stated that before any resident was allowed to self-administer medication, an assessment must be completed. The ED acknowledged when Resident #114 had the medication in their room, the resident had not been assessed to self-administer the medication.

Based on observations, interviews, record review, and facility policy review, the facility failed to provide a comfortable environment and a building in good repair for 2 (Resident #97 and Resident #114) of 3 sampled residents reviewed for the environment.
Findings included:
A review of a facility policy titled, Safe, Clean, Comfortable, and Homelike Environment, implemented in June 2023, revealed, Policy: In accordance with residents' rights, the facility will strive to provide a safe, clean, comfortable, and homelike, allowing the resident to use his or her personal belonging to the extent possible. This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk.
1. A review of Resident #97's admission Record revealed the facility admitted Resident #97 on 04/02/2022 with diagnoses that included acute kidney failure, muscle weakness, and hypertension.
A review of Resident #97's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/09/2023, revealed Resident #97 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact.
On 11/27/2023 at 10:04 AM, 11/28/2023 at 12:45 PM, and 11/20/2023 at 10:47 AM, the surveyor observed Resident #97 as the resident sat in a wheelchair in their room. The glass portion of the sliding glass door that opened to an outside patio was separated from the metal frame and left an approximately 1½ inches wide by 1-foot-long gap in the bottom left side of the sliding glass door. There was a white cloth pushed into the gap of the sliding glass door. Air could be felt when the surveyor stood next to the door. Resident #97 stated the sliding glass door had always had the same gap and the staff placed the cloth into the gap to seal the hole.
In an interview on 11/29/2023 at 2:07 PM, the Director of Maintenance (DOM) stated he made rounds daily to inspect the facility but did not go into each resident's room each day. The DOM stated he had not noticed the hole in Resident #97's sliding glass door. The DOM stated Resident #97 had mentioned cracks around the sliding glass door in the past but not about the hole between the doorframe and glass. The DOM stated he expected a safe, clean, homelike building in good repair.
During an interview on 11/29/2023 at 2:26 PM, the Environmental Services Supervisor (ESS) stated she made rounds three to four times a day but had not noticed the hole in Resident #97's sliding glass door. The ESS stated on daily rounds she looked for safety issues and inspected residents' beds, wiring, bed remotes, bathrooms, doors, and handles. The ESS stated she expected residents to have a safe, clean, homelike building in good repair.
In an interview on 11/30/2023 at 9:45 AM, Assistant Director of Nursing (ADON) #11 stated she made rounds every morning and at the end of the shift but not in every room. Per ADON #11, Resident #97's room was assigned to ADON #9 to monitor since Resident #97 was a long-term resident. ADON #11 stated she expected a safe, clean, comfortable environment that was in good repair.
In an interview on 11/30/2023 at 10:18 AM, the Executive Director (ED) stated the DOM and maintenance technicians were supposed to monitor residents' rooms daily. The ED stated when the nurses, certified nursing assistants, or other staff observed an environmental concern, they should place the concern in the facility's electronic maintenance system. The ED stated he expected a safe, clean, homelike environment with all building components in good repair.
In an interview on 11/30/2023 at 11:45 AM, ADON #9 stated she was responsible for conducting daily room-to-room rounds for long-term care residents. ADON #9 acknowledged Resident #97's room was in her daily room rounds. Per ADON #9, she had not noticed the sliding glass door in disrepair.
2. Review of Resident #114's admission Record, revealed the facility admitted the resident on 09/11/2023 with diagnoses that included wedge compression fracture of thoracic 11 and thoracic 12 vertebra, spondylosis of the lumbar region, intervertebral disc degeneration of the lumbar region, and abnormalities of gait and mobility.
Review of Resident #114's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/20/2023, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact.
On 11/28/2023 at 9:06 AM, Resident #114 stated the cold water from the faucet in their bathroom did not work. When the surveyor turned the faucet to the on position on the cold-water side, no water flowed from the spout.
During an interview on 11/28/2023 at 12:02 PM, Resident #114 stated they had not had cold water in their bathroom since they were admitted to the facility. Resident #114 stated they informed several staff about the lack of cold water. Resident #114 stated they went to the room next door to wash their hands and have access to cold water.
On 11/29/2023 at 7:43 AM, the surveyor noted no cold water flowed from the faucet in Resident #114's room.
In an interview on 11/29/2023 at 2:05 PM, the Director of Maintenance (DOM) stated he had not received a request to fix the lack of cold-water in Resident #114's room.
On 11/29/2023 at 2:29 PM, the DOM confirmed cold water did not flow from the faucet in Resident #114's room The DOM stated it was likely that the nursing staff turned the valve off underneath the sink to stop the cold water from flowing out of the spout.
During an interview on 11/30/2023 at 12:05 PM, Assistant Director of Nursing (ADON) #11 stated it was the nursing staff's responsibility to ensure the residents had a safe and clean environment. ADON #11 stated she was not aware Resident #114 lacked access to cold water in their room.
Durin an interview on 11/30/2023 at 12:18 PM, the Executive Director stated it was his expectation that all resident rooms were in good order and repair.

Based on the interviews, record review, and policy review, the facility failed to ensure 1 (Resident #72) of 4 sampled residents reviewed for nutrition was provided assistance with their meals.
Findings included:
Review of a facility's policy titled, Weight Management, dated August 2014, revealed Residents identified to be at risk of weight variance, will have routine assessment and care plan interventions implemented in accordance with Advance Directives. The objective of this process if to assess, and manage weight variances. The policy specified, 14. Evaluate meal and intake patterns for irregularities; Consider smaller, more frequent meals, or adding calorie dense foods to meals with higher consumption. * Provide oversight of meal intake and offer appropriate substitutes as indicated. Post available substitutes in designated area for staff awareness. * Evaluate level of assistance /supervision needs. Determine if restorative dining, social dining or additional dining assistance during meals is indicated.
Review of Resident #72's admission Record revealed the facility admitted the resident on 03/04/2023. Per the admission Record, Resident #72 had diagnoses to include morbid obesity and dementia.
Review of Resident #72's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/28/2023, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident had moderate cognitive impairment. The MDS indicated Resident #73 required extensive assistance with eating.
Review of Resident #72's care plan initiated on 03/05/2023, revealed the resident had a self-care deficit and required assistance with activities of daily living. Intervention indicated the resident required one-person physical assistance with eating.
During the lunch meal observation on 11/27/2023 at 1:13 PM, Resident #72 was not assisted by staff to eat their meal.
During the lunch meal observation on 11/28/2023 at 12:46 PM, Resident #72 was not assisted by staff to eat their meal.
In an interview on 11/29/2023 at 8:41 AM, Certified Nursing Assistant (CNA) #13 stated Resident #72 did not require staff assistance with eating. According to can #13, she was told the resident was able to eat without staff assistance.
In an interview on 11/29/2023 at 1:23 PM, Resident #72's Responsible Party (RP) stated they were told in a care plan meeting on 11/17/2023 that Resident #72 would be fed during meals.
In an interview on 11/29/2023 at 3:01 PM, CNA #14 stated Resident #72 did not require assistance with eating.
During an interview on 11/29/2023 at 3:15 PM, the Registered Dietician stated he was not aware Resident #72 required assistance with eating.
In an interview on 11/29/2023 at 3:35 PM, Licensed Vocational Nurse (LVN) #2 acknowledged he was assigned to care for Resident #72. LVN #2 stated he was Resident #72 required assistance with eating.
During an interview on 11/29/2023 at 3:41 PM, CNA #15 stated Resident #72 required feeding assistance with meals.
During an interview on 11/29/2023 at 4:20 PM, CNA #17 stated Resident #72 required help with meal setup. Per CNA #17, Resident #72 was able to feed themself.
During an interview on 11/30/2023 at 10:41 AM, Assistant Director of Nursing (ADON) #11 stated if a resident had documented on their care plan to have one person physical assistance with meals, , the nursing staff must provide physical assistance with eating.
In an interview on 11/30/2023 at 12:28 PM, the Executive Director stated if the resident was care planned for assistance with eating, the nursing staff must ensure the resident received assistance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide chlordiazepoxide-clidinium (medication to help treat stomach disorders) as ordered by a physician for one of three sampled residents (Resident 1) when the medication was not administered two times a day for four days for treatment of Resident 1's gastritis (inflammation of the lining of the stomach).
This failure had the potential for Resident 1 to experience weight loss due to lack of appetite caused by abdominal pain.
Findings:
During a review of Resident 1 ' s admission Record(AR), the AR indicated, Resident 1 had diagnosis of hypertension (high blood pressure in the vessels that carry blood from the heart to the rest of the body), Parkinson's disease (brain disorder that causes unintended or uncontrollable movements such as shaking, stiffness, and difficulty with balance and coordination), irritable bowel syndrome (a group of symptoms that affect your digestive system with excessive gas, abdominal pain and cramps), gastro-esophageal reflux (condition occurred by when stomach acid repeatedly flows back into the esophagus causing irritation) and gastritis (inflammation of stomach). Resident 1 was admitted to the facility on [DATE] for rehabilitation after C3 fracture (a break in the third cervical vertebra, which is part of spine in the neck).
During a review of Resident 1's Physician order (PO), dated 3/2022, the PO indicated, [Brand name] chlordiazepoxide-clidinium capsule 5-2.5 MG (milligram-a unit of mass or weight equal to one thousandth of a gram) two times a day for gastritis was ordered on 2/25/22 at 9:05 p.m.
During a review of Resident 1 ' s Medication Administration Record (MAR), dated [DATE], the MAR indicated, chlordiazepoxide-clidinium was not administered as ordered on 2/26, 2/27 and 2/28.
During a review of Resident 1's MAR, dated March 2022, the MAR indicated, chlordiazepoxide-clidinium was not given on 3/1/22. The MAR indicated, the first dose of [chlordiazepoxide-clidinium] was administered on 3/2/22 at 4:30 p.m.
During a review of Resident 1's MD [Doctor of Medicine]/NP [nurse practitioner] /PA [physician assistant] Progress Note dated 3/2/22 at 4:17 p.m., the MD/NP/PA Progress Note indicated, .[Resident 1] states that she has not been getting the [chlordiazepoxide-clidinium]. Because she is not getting [chlordiazepoxide-clidinium] she is having abd [abdominal] pain daily which causing her appetite to decline .Will discuss her order [chlordiazepoxide-clidinium] with nursing staff .
During a phone interview on 2/28/23, at 3:50 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 validated the initials on Resident 1's MAR on 2/26/22, 2/27/22, 2/28/22 and 3/1/22 indicated, chlordiazepoxide-clidinium was not administered. LVN 1 stated, [chlordiazepoxide-clidinium] was not available to administer to Resident 1. LVN 1 stated the pharmacy did not send the medication. LVN 1 stated, she did not notify the physician or make any further efforts to determine why the medication was not available. LVN 1 stated Resident 1 did not receive the prescribed medication for four days.
During an interview on 3/22/22, at 10:30 a.m., with the Director of Nursing (DON), the DON stated, Any medication not given to [Resident 1] should have been entered in the MAR and the nurse should have notified the MD [medical doctor].
During a review of the facility's policy and procedure (P&P) titled, Medication Shortages/Unavailable Medications, dated 1/1/13, indicated, .If the medication is unavailable from Pharmacy, and cannot be supplied from the manufacturer, Facility should obtain alternate Physician/Prescriber orders, as necessary .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 2/12/19 at 3:24 p.m., during a concurrent observation and interview in the medication room at Station 2 with Registered Nurse (RN) 3, there were two boxes of Biscolax suppositories (laxative medication) stored on the shelf at room temperature. RN 3 stated, These [the suppositories] should be in the refrigerator. RN 3 moved two boxes of Biscolax suppositories to the refrigerator in the medication room at Station 2.
Review of the Biscolax suppository box indicated under the instructions to store at 68 to 77 degrees Fahrenheit (F).
Review of the facility's temperature log for February 2019 for the medication room at Station 2 indicated the temperature reading were greater than 77 degrees F on 10 out of 23 readings.
Review of the facility's temperature log for January 2019 for the medication room at Station 2 indicated the temperature reading were greater than 77 degrees F on 13 out of 62 readings.
Review of the facility's temperature log for December 2018 for the medication room at Station 2 indicated the temperature reading were greater than 77 degrees F on 31 out of 31 readings.
https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=2a1b271e-ae17-4284-bfa1-4d0e3c75fcc3 dated 1/14/19, indicated .Label: Biscolax - bisacodyl suppository .store at room temperature .68-77 degrees .
Based on observation and interview, the facility failed to properly and safely store medications in the facility when:
1. Resident 50's medications were left on the medication cart (med cart 3A) not in sight of the licensed nurse (LN).
2. Medication cart on Station 4 was found unlocked, and no Licensed Nurse (LN) staff in sight.
3. Suppositories were stored in Medication room [ROOM NUMBER] at a temperature that was too warm which was?
These failures had the potential risk for unauthorized access to medications from residents and staff, and for residents to receive potentially ineffective medication stored at inappropriate temperatures.
Findings:
1. On 2/13/19 at 4:23 p.m., during a medication administration observation on Station 3, Licensed Vocational Nurse (LVN) 5 placed three medication cards (containing medications) on top of the medication cart and then placed a box of gloves on top of the medication cards. LVN 5 proceeded to enter Resident 50's room. LVN 5 did not put the medication cards back into the medication cart.
On 2/13/19 at 4:58 p.m., during an interview, LVN 5 stated she should have put the medications away in the medication cart after using the medications. LVN 5 stated anyone could have taken the medications when left on the cart.
2. On 2/12/19 at 3:19 p.m., during an observation on Station 4, a medication cart was unlocked in front of Station 4 nursing desk. There were no licensed nurses near the medication cart.
On 2/12/19 at 3:21 p.m., during a concurrent observation and interview, LVN 7 observed the medication cart and stated the medication cart was unlocked. LVN 7 stated the medication cart should be kept locked because medications could be removed. LVN 7 stated she stepped away from the med cart and did not lock the med cart when she walked away.
On 2/15/19 at 7:49 a.m., during an interview, the assistant director of nursing (ADON) stated the licensed nurses should lock the medication cart when not in sight of the medication cart. The ADON stated the medications could be taken and ingested by the residents if the medications were left open.
The facility policy and procedure titled, General Dose Preparation and Medication Administration, dated 12/1/07, indicated, .3.9 Facility staff should not leave medications or chemicals unattended . 7. Facility should ensure that medication carts are always locked when out of sight or unattended .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 46) received services consistent with professional standards of practice when Resident 46 was assessed as a high risk to develop a pressure ulcer (localized damage to skin or underlying tissue over bony prominence as a result of pressure) developed a pressure ulcer and was not repositioned a minimum of every 2 hours to help prevent a pressure ulcer.
This failure contributed to Resident 46's development of a stage 2 pressure ulcer (partial-thickness loss of skin with exposed dermis).
Findings:
Review of Resident 46's clinical record, titled, Facesheet (a document containing resident profile information) indicated Resident 46 was admitted to the facility on [DATE] with diagnoses which included hemiplegia (complete paralysis of half of the body), hemiparesis (weakness of one entire side of the body) following cerebral infarction (a portion of the brain that has restricted blood supply) and morbid obesity (a disorder involving excessive body fat that increases health problems).
Review of Resident 46's clinical record, titled, Minimum Data Set (MDS) assessment (an evaluation of a resident's cognitive and functional status) dated 12/14/18, indicated Resident 46's Brief Interview for Mental Status (BIMS- an assessment of cognitive status) score was three of 15 which indicated Resident 46 had severe cognitive impairment (unable to make decisions and good judgement).The MDS assessment section G for functional status, indicated, Resident 46 was totally dependent on staff members for transfers from one surface to another surface. Under section M for skin conditions, Resident 46 was coded at risk for pressure ulcers/injuries.
On 2/13/19 at 8:29 a.m., during observation in Resident 46's room, Resident 46 laid in bed in supine (on the back) position with head of bed elevated and pillows on Resident 46's side extremities (legs and arms). Resident 46 did not answer questions.
On 2/13/19 at 8:32 a.m., during a concurrent observation and interview, in Resident 46's room, certified nursing assistant (CNA) 2 turned Resident 46 to her left side. Resident 46 had feces and urine on her bottom and in her brief. Resident 46's buttock area was observed to be red and had an open wound on the coccyx (tailbone area) and no wound dressing in place. CNA 2 stated she had not seen the open wound until now. CNA 2 stated the open wound was new.
Review of Resident 46's clinical record, titled, Care plan dated 11/23/17, indicated, Potential for pressure ulcer development/skin breakdown, bruise, skin tear r/t [related to] . Interventions/Task . assist with reposition in bed every 2 hours and as needed .
Review of Resident 46's clinical record, titled, Care plan, dated 6/10/18, indicated, Chronic excoriation (wearing off the skin) to sacrococcyx (tailbone) area . Interventions .Turn and reposition Q [every] 2 hours .
On 2/13/19 at 10:58 a.m., during an interview, licensed vocational nurse (LVN) 1 stated one of the interventions to prevent pressure ulcers for Resident 46 was to reposition her every two hours. LVN 1 stated nursing staff were aware Resident 46 was identified as high risk to develop pressure ulcers. LVN 1 stated the pressure ulcer on Resident 46's coccyx was new and avoidable. LVN 1 stated we could have repositioned Resident 46 more frequently to make sure Resident 46 was clean and dry to prevent the development of the pressure ulcer.
On 2/13/19 at 2:41 p.m., during a concurrent interview and record review, the assistant director of nursing (ADON) stated the newly discovered wound [identified on 2/13/19 by surveyor] was assessed and was a stage 2 pressure ulcer. ADON stated the facility did not have documentation of the wound because the staff had not identified the wound until the surveyor saw the wound. The ADON stated Resident 46 was assessed as a high risk to develop pressure ulcers. The ADON stated one of the interventions for Resident 46 to prevent pressure ulcer was to reposition every two hours. The ADON stated the nurse needed to be more vigilant in making sure CNAs repositioned Resident 46. The ADON stated CNAs should be repositioning residents during daily care. The ADON reviewed the clinical record and was unable to find documentation regarding repositioning Resident 46. ADON stated repositioning Resident 46 was not documented in the clinical record.
On 2/13/19 at 3:30 p.m., during an interview, the director of nursing (DON) stated Resident 46 was incontinent (unable to hold) of urine due to Resident 46 receiving enteral feedings. The DON stated Resident 46 needed to be checked and repositioned more frequently than every two hours. The DON stated resident repositioning was part of the CNA's daily care being provided to residents.
Review of the facility policy and procedure titled, Pressure Ulcer, Prevention of dated 2006, indicated . Procedure . 10. Established a timing and positioning schedule in bed and chair to meet the resident's needs . DOCUMENTATION GUIDELINES . Date, time, approaches to prevent pressure ulcer development .
Review of administrative policy and procedure titled, [name of facility] Skin Integrity Standard, dated, 7/18, indicated, PRACTICE: Patients identified to be at risk for skin breakdown (pressure ulcer) will have a routine assessment . Established a turning and positioning and/or heel elevation program based upon patient assessed clinical condition while in bed or in a chair with documentation of the established program/frequency determined .
On 2/13/19 at 4:11 p.m., during an observation in Resident 46's room, Resident 46 laid in bed on her right side (facing the window) with eyes closed.
On 2/13/19 at 5:54 p.m., during an observation in Resident 46's room, Resident 46 laid in bed on her right side (facing the window) with eyes closed.
On 2/13/19 at 6:28 p.m., during an observation in Resident 46's room, Resident 46 laid in bed on her right side (facing the window) with eyes closed.
On 2/14/19 at 7:50 a.m., during an observation in Resident 46's room, Resident 46 laid in bed on her left side (facing the door) with eyes closed.
On 2/14/19 at 8:47 a.m., during an observation in Resident 46's room, Resident 46 laid in bed on a supine position (face and torso facing up) with head of bed at 30 degrees.
On 2/14/19 at 11:00 a.m., during an observation in Resident 46's room, Resident 46 laid in bed in a supine position with head of bed at 30 degrees.
On 2/14/19 at 1:14 p.m., during an observation in Resident 46's room, Resident 46 laid in bed on a supine position with head of bed at 30 degrees.
On 2/14/19 at 3:29 p.m., during an observation in Resident 46's room, Resident 46 laid in bed on a supine position with head of bed at 30 degrees.
On 2/14/19 at 3:38 p.m., during an interview, CNA 1 stated she was taking care of Resident 46. CNA 1 stated she did not reposition Resident 46 during the eight hours of her morning shift.
Review of the facility policy and procedure titled, Pressure Ulcer, Prevention of dated 2006, indicated . Procedure . 10. Established a timing and positioning schedule in bed and chair to meet the resident's needs . DOCUMENTATION GUIDELINES . Date, time, approaches to prevent pressure ulcer development .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to timely revise and implement a person centered comprehensive care plan for two of 111 sampled residents (Resident 53 and Resident 111) when:
1. Resident 53's care plan on fluid restriction did not reflect the specific amount of fluids Resident 53 could have in a day.
2. Resident 111's care plan interventions for the use of an anticoagulant medication, warfarin, were not revised to include risk for bleeding.
These failures had the potential to result in Resident 53's fluid and hydration needs going unmet and Resident 111 to experience bleeding and injuries while receiving an anticoagulant medication.
Findings:
1. Review of Resident 53's facesheet (a document containing resident profile information) indicated Resident 53 was admitted to the facility with diagnoses of dysphagia (difficulty in swallowing), congestive heart failure (weakness of the heart that leads to a buildup of fluid in the lungs and surrounding body tissues) and chronic kidney disease (a condition characterized by a gradual loss of kidney function over time). Resident 53's Minimum Data Set (MDS) assessment (an evaluation of a resident's cognitive and functional status) dated 12/28/18, indicated a Brief Interview for Mental Status (BIMS)(assessment of cognitive status) score of 11 of 15 which indicated Resident 53 had moderate cognitive impairment (memory, recall and judgement).
Review of Resident 53's physician orders, dated 12/14/18, indicated, . Fluid Restriction 2000 milliliters [ml][unit of measurement] total in 24 [hours] as follows: Dietary [Department] 1080 ml [breakfast 480 ml, lunch 360 ml, dinner 240 ml . Nursing [Department . 920 ml (days 500 ml, [afternoon shift] 300 ml, [night shift] 120 ml .)
On 2/12/19 at 12:29 p.m., during a concurrent observation and interview in the social dining room, Resident 53 stated with a loud tone of voice, I want coffee and water right now. Resident 53 was eating his lunch meal and there was no water or drinks available on his meal tray. Resident 53 stated, I need water to drink while I'm eating. There were Certified Nursing Assistants (CNA)s in the social dining room who did not provide fluids to drink for Resident 53.
On 2/12/19 at 12:31 p.m., during an observation in the social dining room, Resident 53 was eating with no water or drink on his meal tray.
On 2/12/19 at 12:35 p.m., during a concurrent observation and interview in the social dining room, Resident 53 continued eating with no water or fluids on his lunch tray. Resident 53 stated, I still need water, nobody has given me any water to drink.
On 2/12/19 at 12:36 p.m., during a concurrent observation and interview in the social dining room, CNA 9 stated, [Resident 53] does not get water in his tray because he is on fluid restriction. He does not drink water with lunch. He is on fluid restriction.
On 2/12/19 at 12:37 p.m., during a concurrent observation and interview in the social dining room, Resident 53 stated, It's so hard to eat with no water. I want to drink water. Resident 53 had no water or fluids at this time on his tray.
On 2/12/19 at 12:38 p.m., during a concurrent interview and record review, licensed vocational nurse (LVN) 3 reviewed Resident 53's clinical record in the computer and stated Resident 53 was on fluid restriction. LVN 3 stated Resident 53 was on 2000 ml [unit of measure]/hour (hr) fluids per day and received 360 ml for lunch. LVN 3 stated Resident 53 should get 360 ml fluids for lunch.
On 2/12/19 at 12:39 p.m., during a concurrent observation and interview, LVN 3 stated, I don't see water or fluids in [Resident 53's] tray and he should have gotten 360 ml of water. LVN 3 did not respond why Resident 53 had no fluids on his lunch tray and was asked what the risk was when Resident 53 was eating without any fluids; LVN 3 did not respond.
On 2/12/19 at 12:41 p.m., during a concurrent observation and interview, Resident 53 continued eating with no water and fluids. Resident 53 stated, I want water when I am eating. It's so difficult to eat without having any water. I just keep shoving the food inside my mouth and I am not drinking water. It's just so hard.
On 2/12/19 at 2:50 p.m., during an interview, the registered dietitian (RD) stated when a resident is on fluid restriction, the facility customized their fluid intake per meals. The RD stated Resident 53 should have received fluids during meal time.
Review of Resident 53's lunch meal slip [ticket] dated 2/12/19, indicated, . Preferences . 8 [ounce] water .
On 2/12/19 at 3:26 p.m., during a concurrent interview and record review, LVN 5 stated Resident 53 was on fluid restriction because he had chronic kidney disease. LVN 5 reviewed Resident 53's care plan for the fluid restriction and could not find a specific care plan that addressed the specific amount of fluid Resident 53 could have in a day. LVN 5 stated, I don't see a very specific care plan for the fluid restriction. LVN 5 stated, The care plan should be specific and should indicate how many [ml's] of fluids per shift the resident gets from dietary and nursing but I don't see one.
On 2/13/19 at 3:37 p.m., during an interview, the director of nursing (DON) stated, The fluid restriction amount of fluids does not have to be in the care plan because its already in the [Medication Administration Record- MAR].
On 2/14/19 at 11:20 a.m., during a concurrent interview and record review, the DON reviewed the facility policy and procedure titled, Fluid Restriction dated 8/14 which indicated if the resident was on fluid restriction, it should be documented in the care plan identifying fluids provided by dietary department and nursing services. The DON stated it was documented in the MAR but not in Resident 53's care plan.
On 2/14/19 at 1:15 p.m., during an interview, the DON stated when a resident was on fluid restriction, it should be documented in the care plan.
The facility policy and procedure titled, Fluid Restriction dated 8/14, indicated, . Fluid restrictions will be followed per physician order and monitored by nursing staff for resident compliance . 5. Fluid Restriction is documented on the MAR and care plan, identifying fluids provided by Dietary Department and Nursing Services . Care Plan Documentation Guidelines . Approaches . Amount of fluids which may be provided by dietary and nursing each shift .
2. Review of Resident 111's facesheet indicated Resident 111 was admitted on [DATE] with diagnosis of atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow).
On 2/13/19 at 10:46 a.m., during a concurrent interview and record review, registered nurse (RN) 2 stated Resident 111 had a diagnosis of atrial fibrillation and had an physician's order for warfarin (a blood thinner medication) since December 2018. RN 2 stated the licensed nurses should assess for bruising and bleeding when on warfarin. RN 2 stated there should be a care plan for warfarin for the licensed nurses to know what to assess. RN 2 stated the care plan for peripheral vascular disease (narrowed blood vessels reduce blood flow to the limbs) includes interventions for anticoagulant.
Review of Resident 111's care plan dated 1/2/19, indicated The resident has Peripheral Vascular Disease (PVD) r/t [related to] Diabetes [body's inability to produce any or enough insulin] .Interventions .Give medications for improved blood flow or anticoagulants as ordered . The care plan interventions did not include risk for bleeding when receiving an anticoagulant.
Review of Resident 111's care plan dated 12/30/18, indicated, The resident has altered cardiovascular status r/t [related to] A fib [atrial fibrillation] .Interventions .Monitor/document/report PRN [as needed] any s/sx [signs and symptoms] of CAD [coronary artery disease][damage to the heart's major blood vessels]: chest pain or pressure especially with activity, heartburn, nausea, and vomiting, shortness of breath, excessive sweating, dependent edema, changes in cap [capillary] refill, color/warmth of extremities .
On 2/13/19 at 11:47 a.m., during a concurrent interview and record review, the DON stated the licensed nurses monitor for bleeding when Resident 111 returns from dialysis (process of purifying the blood of a person whose kidneys are not working normally). The DON stated the care plan did not address what the licensed nurses should monitor for when receiving an anticoagulant such as tarry stool or bleeding gums. The DON stated interventions to monitor for bleeding should be in the care plan.

Based on observation, interview, and record review, the facility failed to implement a comprehensive person centered care plan when:
1. Resident 42's hearing aid device was not care planned.
2. Resident 52's difficulty with hearing was not care planned.
These failures had the potential for Resident 42 and Resident 52 to not adequately be assessed for hearing impairment needs, possible misplacement, and needs not being met.
Findings:
1. On 2/12/19 at 9:53 a.m., during a concurrent observation and interview, Resident 42 had a hearing aid placed in the right ear. Resident 42 stated she was in an accident when she was younger and lost hearing in the right ear. Resident 42 stated she did not need one for the left ear. During the interview, Resident 42 would lean forward to hear questions.
Review of Resident 42's facesheet (a document with personal identifiable information) indicated Resident 42 was admitted to the facility with diagnosis of bilateral hearing loss.
On 2/14/19 at 7:56 a.m., during a concurrent interview and record review, the assistant director of nursing (ADON) reviewed Resident 42's medical record and was unable to find a hearing impairment and hearing aide devise care plan. ADON stated the licensed nurses should have developed a care plan for the hearing aid to provide information to staff regarding hearing impairment. The ADON stated the licensed nurses and CNAs should be monitoring for hearing aid use and placement.
On 2/14/19 at 8:40 a.m., during a concurrent interview and record review, Minimum Data Set Coordinator (MDSC) 2 reviewed the MDS assessment (an evaluation of a resident's cognitive and functional status) dated 12/12/18 and stated Resident 42 had a hearing aid. MDSC 2 reviewed Resident 42's care plan and stated there was no care plan for hearing impairment or the hearing aid used by Resident 42. MDSC 2 stated there should be a care plan for hearing devices used by residents. MDSC 2 stated licensed nurses were responsible for developing care plans.
2. On 2/12/19 at 3:45 p.m., during an interview, Resident 52 stated she could not hear and needed speaker to come closer to her. Resident 52 stated she wore a hearing aid in the right ear. Resident 52 stated it has three months since her hearing aid was lost. Resident 52 stated she can hear better with the hearing aids. Resident 52 stated she feels terrible that she cannot hear.
Review of Resident 52's MDS assessment section B for hearing, speech, and vision dated 12/14/18, indicated Resident 52 had moderate difficulty with hearing (speaker has to increase volume and speak distinctly) and used hearing aids.
On 2/12/19 at 3:56 p.m., during an interview, certified nursing assistant (CNA) 3 stated Resident 52 was hard of hearing. CNA 3 stated she had to speak louder and close to Resident 52 to hear.
On 2/12/19 at 3:58 p.m., during a concurrent interview and record review, licensed vocational nurse (LVN) 2 stated Resident 52 was hard of hearing. LVN 2 reviewed Resident 52's care plan and could not find a care plan for hearing difficulty. LVN 2 stated Resident 52's hearing difficulty should be care planed.
On 2/12/19 at 4:50 p.m., during a concurrent interview and record review, MDSC 1 reviewed Resident 52's care plan and was unable to find a hearing difficulty care plan. MDSC 1 stated Resident 52's hearing difficulty should be care plan.
On 2/13/19 at 9:28 a.m., during a concurrent interview and record review, MDSC 1 stated a previous care plan dated 9/11/18 for hearing difficultly was not carried over to the current care plan when Resident 52 was readmitted to the facility. MDSC 1 stated the care plan was canceled on 12/3/18. MDSC 1 stated Resident 52's hearing difficulty care plan should have been carried over to the current care plan.
On 2/13/19 at 2:36 p.m., during an interview, the ADON stated Resident 52's hearing difficulty should to be in the care plan. The ADON stated the interventions for hearing difficulty should be placed on the care plan.
On 2/13/19 at 4:04 p.m., during an interview, the director of nursing stated Resident 52's hearing difficulty should be care planned and care plan interventions should be specific to Resident 52.
The facility policy and procedure titled, Care Plan, Comprehensive dated 12/17, indicated . POLICY .Plans are reviewed and revised by the IDT (a facility group composed of a physician, a registered nurse, a social worker and additional appointed facility staff) at least quarterly, following completion of the MDS assessment or following an assessment for a significant change of condition . PURPOSE To support and guide resident and IDT collaboration to achieve and maintain optimal resident health, function and quality of life . PROCEDURE 1. Care plan are individualized through the identification of resident concerns, unique characteristics, strengths and individual needs. 2. Care plans are based on using fundamental information gathered by the MDS, CAA's and information gathered through observation and evaluation. 3. Care plans become a comprehensive tool for the IDT to utilized as a reference for identified concerns and approaches to established guidance for meeting resident individual needs .
The facility policy and procedure titled Hearing Aid, Use and Care of dated 2006, indicated .CARE PLAN DOCUMENTATION GUIDELINES .Problem: Identify the appropriate problem under which to list the hearing aid as an approach. Consider listing possible risks and complications .

Based on interview and record review, the facility failed to complete the Advance Beneficiary Notice (ABN 10055) for discontinued services, with the appeal contact information for one of 111 sampled residents (Resident 48).
This failure resulted in Resident 48 not to be advised of rights and potential costs for services Resident 48 could be charged in advance.
Findings:
On 2/13/19 at 11:46 a.m., during a concurrent interview and record review, the business office manager (BOM) stated Resident 48 had days remanding under Medicare part A services (for payment). The BOM stated she did not go back to Resident 48 to sign the advanced beneficiary notice (ABN) letter when it was determined Resident 48 was staying in the facility after discharged from Medicare part A services. The BOM stated the ABN letter should be given to the resident when the Notice of Medicare Non-Coverage (NOMNC) letter was signed.
Review of Resident 48's NOMNC letter dated 10/10/18, indicated Resident 48 signed and dated the form on 10/10/18.
On 2/15/19 at 9 a.m., during an interview, the director of nursing (DON) stated the facility did not have a policy for NOMNC and ABN letters.
On 2/15/19 at 3:30 p.m., during a concurrent interview and record review, the business office assistant (BOA) stated when the business office became aware Resident 48 would stay in the facility past the approved Media-care days, the facility should have issued the ABN letter. The BOA stated the ABN letter informed resident of the cost of skilled nursing services. The BOA reviewed the form titled, Medicare/[name of insurance] Status Change, dated 10/10/18 and stated the BOM signed for acknowledgement of Resident 48's stay in the facility. The DOM stated Resident 48 was not provided the NOMNC letter in advance.

Based on observation, interview, and record review, the facility failed to provide reasonable accommodations for four of 111 sampled residents (Residents 62, 73, 66, and 105) when:
1.
Resident 62's call light (a device used to alert staff when a resident needs assistance) was wrapped around her nightstand out of Resident 62's reach while in her wheelchair.
2.
Resident 73's call light was found on the floor out of Resident 73's reach.
3.
Resident 66's call light was found on the floor out of reach while Resident 66 laid in bed.
4.
Resident 105's call light was found on the floor out of reach of Resident 105.
These failures had the potential for the residents not to receive assistance when needed and assistance in case of emergency.
Findings:
1. On 2/12/19 at 12:08 p.m., during a concurrent observation and interview in Resident 62's room, Resident 62 sat in a wheelchair near the foot of the bed. Resident 62 faced the head of the bed. Resident 62 stated, Help me please. Resident 62 stated she came back from an appointment and needed help taking off her jacket. Resident 62 stated she could not reach her call light. Resident 62 stated she could not move her wheelchair to get to the call light. The call light was wrapped around Resident 62's nightstand handle. Resident 62 stated someone dropped her off in her room after her appointment.
Review of Resident 62's Minimum Data Set (MDS) assessment (an evaluation of a resident's cognitive and functional status) under section C dated 12/27/18, indicated Resident 62 was cognitively intact (in memory and judgment). Under section G for functional status, the document indicated Resident 62 did not walk in her room and used a wheelchair for mobility.
On 2/12/19 at 12:13 p.m., during a concurrent observation and interview, registered nurse (RN) 1 stated the call light should not be wrapped around the nightstand handle. RN 1 stated the call light should be close by the resident and should be freely accessible. RN 1 stated Resident 62 may not have her needs attended to without having the call light with her.
3. Review of Resident 66's MDS assessment section C dated 12/28/18, indicated Resident 66 had moderate cognitive impairment. Section G for functional status indicated Resident 66 did not walk and used a wheelchair for mobility.
On 2/12/19 at 8:42 a.m., during a concurrent observation and interview in Resident 66's room, Resident 66 was eating in bed. The call light was found on the floor. Resident 66 stated he did not know where his call light was. Resident 66 stated he usually yelled for staff when he needed to call for help.
On 2/12/19 at 9:05 a.m., during a concurrent observation and interview, CNA 15 stated the call light was on the floor. CNA 15 stated the call light might have slid to the floor. CNA 15 stated call lights were important so that resident needs would be attended.
On 2/12/19 at 9:07 a.m., during a concurrent observation and interview, LVN 6 stated the call light should be within reach for every resident to meet their needs and prevent injury.
2. Review of Resident 73's facesheet (a document containing resident profile information) indicated Resident 73 was admitted to the facility with a history of falling.
On 2/12/19 at 9:10 a.m., during an observation in Resident 73's room, Resident 73 laid in bed with eyes closed. Resident 73's call light was on the floor.
On 2/12/19 at 9:12 a.m., during a concurrent observation and interview in Resident 73's room, certified nursing assistant (CNA) 5 asked Resident 73 to use the call light. Resident 73 stated, I don't know where it [call light] is. CNA 5 stated Resident 73's call light was on the floor. CNA 5 stated Resident 73 would not be able to reach and use his call light to ask for help if it was needed.
On 2/12/19 at 10:59 a.m., during a concurrent observation and interview in Resident 73's room, licensed vocational nurse (LVN) 1 asked Resident 73 to use the call light. Resident 73 was able to demonstrate on how to use the call light. LVN 1 stated the call light should be where Resident 73 could reach it all times and should not be on the floor.
4. On 2/12/19 at 4:10 p.m., during a concurrent observation and interview in Resident 105s room, the call light for Resident 105 was found behind the bed on the floor. CNA 18 stated Resident 105 should have a call light within reach. CNA 18 stated Resident 105 dropped the call light when he moved around. CNA 18 stated there was no clip on the call light to attach it to an area where the resident can use.
Review of Resident 105's MDS assessment section C dated 1/21/19, indicated Resident 105 was cognitively intact. Section G: functional status, indicated Resident 62 did not walk and used a wheelchair for mobility.
On 2/13/19 at 11:09 a.m., during an interview, RN 2 stated the call light should be next to the resident to enable the resident to call for help when needed.
The facility policy and procedure titled, Call Light, Use of dated 2006, indicated, BASIC RESPONSIBILITY Licensed Nurse and Nursing Assistant, all Facility Staff . PURPOSE, To respond promptly to resident's call for assistance. To assure call system is in proper working order . 8. When providing care to residents be sure to position the call light conveniently for the resident to use. Tell the resident where the call light is and show him/her how to use the call light . 11. Be sure all call lights are placed on the bed at all times, never on the floor or bedside stand .

Based on observation, interview, and record review, the facility failed to maintain proper hydration for one of 111 sampled residents (Resident 53) consistent with resident needs and preferences when Resident 53 was not provided fluids during lunch.
This failure placed Resident 53 at risk of not having sufficient fluid intake to maintain proper hydration and placed Resident 53 at risk of dehydration.
Findings:
Review of Resident 53's clinical record, titled, Facesheet (a document containing resident profile information) indicated Resident 53 was admitted to the facility with diagnoses of dysphagia (difficulty in swallowing), congestive heart failure (weakness of the heart that leads to a buildup of fluid in the lungs and surrounding body tissues) and chronic kidney disease (a condition characterized by a gradual loss of kidney function over time). Resident 53's Minimum Data Set (MDS) assessment (an evaluation of a resident's cognitive and functional status) dated 12/28/18, indicated a Brief Interview for Mental Status (BIMS)(assessment of cognitive status) score of 11 of 15 points which indicated Resident 53 had moderate cognitive impairment (memory, recall and judgement).
Review of Resident 53's clinical record, titled, Physician orders dated 12/14/18, indicated, . Fluid Restriction 2000 milliliters [ml][unit of measurement] total in 24 [hours] as follows: Dietary [Department] 1080 ml [breakfast 480 ml, lunch 360 ml, dinner 240 ml . Nursing [Department . 920 ml (days 500 ml, [afternoon shift] 300 ml, [night shift] 120 ml .)
On 2/12/19 at 12:29 p.m., during a concurrent observation and interview in the social dining room, Resident 53 stated with a loud tone of voice, I want coffee and water right now. Resident 53 was eating his lunch meal and there was no water or drinks available on his tray for him to drink. Resident 53 stated, I need water to drink while I'm eating. There were CNAs in the social dining room and did not provide drinks to Resident 53.
On 2/12/19 at 12:31 p.m., during an observation in the social dining room, Resident 53 was eating with no water or drink on his tray.
On 2/12/19 at 12:35 p.m., during a concurrent observation and interview in the social dining room, Resident 53 continued eating with no water or fluids on his lunch tray. Resident 53 stated, I still need water, nobody has given me any water to drink.
On 2/12/19 at 12:36 p.m., during a concurrent observation and interview in the social dining room, certified nursing assistant (CNA) 9 stated, [Resident 53] does not get water in his tray because he is on fluid restriction. He does not drink water with lunch. He is on fluid restriction.
On 2/12/19 at 12:37 p.m., during a concurrent observation and interview in the social dining room, Resident 53 stated, It's so hard to eat with no water. I want to drink water. Resident 53 had no water or fluids at this time on his tray.
On 2/12/19 at 12:38 p.m., during a concurrent interview and record review, licensed vocational nurse (LVN) 3 reviewed Resident 53's clinical record in the computer and stated Resident 53 was on fluid restriction. LVN 3 stated Resident 53 was on 2000 ml/hour (hr) fluids per day and receives 360 ml for lunch. LVN 3 stated Resident 53 should get 360 ml fluids for lunch.
On 2/12/19 at 12:39 p.m., during a concurrent observation and interview, LVN 3 stated, I don't see water or fluids in [Resident 53's] tray and he should have gotten 360 ml of water. LVN did not respond why Resident 53 had no fluids on his lunch tray and was asked what the risk was when Resident 53 was eating without any fluids and did not respond.
On 2/12/19 at 12:41 p.m., during a concurrent observation and interview, Resident 53 continued eating with no water and fluids. Resident 53 stated, I want water when I am eating. It's so difficult to eat without having any water. I just keep shoving the food inside my mouth and I am not drinking water. It's just so hard.
On 2/12/19 at 2:50 p.m., during an interview, the registered dietitian (RD) stated when a resident was on fluid restriction, the facility customized their fluid intake per meals. The RD stated Resident 53 should have received fluids during meal time.
Review of Resident 53's lunch meal slip [ticket] dated 2/12/19, indicated, . Preferences . 8 [ounce] water .
On 2/12/19 at 3:26 p.m., during a concurrent interview and record review, LVN 5 stated Resident 53 was on fluid restriction because he had chronic kidney disease. LVN 5 reviewed Resident 53's care plan for the fluid restriction and could not find a specific care plan that addressed the specific amount of fluid Resident 53 could have in a day. LVN 5 stated, I don't see a very specific care plan for the fluid restriction. LVN 5 stated if a resident was on fluid restriction, the fluids should be distributed throughout the day. LVN 5 stated, [Resident 53] always had to have fluids while he eats. LVN 5 stated it was a risk of choking if Resident 53 did not have fluids on his tray while he was eating his lunch meal.
On 2/13/19 at 3:37 p.m., during an interview, the director of nursing (DON) stated, When [the facility] have an order for fluid restriction, dietary is notified. We have a process, how many [ml's] for nursing and for dietary. One thousand [ml] is for dietary. [Residents] should get water with their tray. Fluids should be part of their [meal] tray.
The facility policy and procedure titled, Fluid Restriction dated 8/14, indicated, . Fluid restrictions will be followed per physician order and monitored by nursing staff for resident compliance . Procedure . 2. Licensed nursing staff and the dietary shall collaborately determine the amount of fluid restriction to be used by nursing each shift .

3. On 2/12/19 at 11:41 a.m., during an observation in Resident 75's room, Resident 75's urinal containing urine was found hanging on the trash bin. The trash bin contained trash inside where the urinal hung.
On 2/12/19 at 11:48 a.m., during an interview, LVN 1 stated Resident 75's urinal should not hang on the trash bin. LVN 1 stated hanging the urinal on the trash bin could cause infection to Resident 75. LVN 1 stated Resident 75's urinal should be placed in a plastic bag and hang on the bed frame.
On 2/12/19 at 11:55 a.m., during an interview, CNA 4 stated Resident 75's urinal should be hang on the bed frame and not on the trash bin.
On 2/13/19 at 4:15 p.m., during an interview, the ADON stated stated Resident 75's urinal should not hang on the trash bin. The ADON stated Resident 75's urinal should be place in a plastic bag and hang on Resident 75's bed frame.
Review of the facility policy and procedure titled, INFECTION PREVENTION PROGRAM OVERVIEW dated 2012, indicated, I. GOALS . A. Decrease the risk of infection to residents and personnel. B. Monitor for occurrence of infection and implement appropriate control measures. C. Identify and correct problems relating to infection practices. D. Maintain compliance with state and federal regulations relating to infection prevention .Staff and resident education focuses on risk of infection and decrease risk. Policies, procedures and aseptic practices are followed by personnel in performing procedures and in disinfection of equipments .
2. During a clinical record review of Resident 6's Minimum Data Set (MDS) assessment (an evaluation of a resident's cognitive and functional status] under section C dated 11/14/18, indicated a Brief Interview for Mental Status(BIMS)(an assessment of a resident's cognitive status) score of 14 of 15 points which indicated Resident 6 was cognitively intact (memory, recall and judgement). Under section G for functional status, Resident 6 required extensive assistance with two person physical assist for toileting use, personal hygiene, dressing and used a wheelchair for mobility.
On 2/12/19 at 9:34 a.m., during a concurrent observation and interview, Resident 6 was in bed with a urinal on the floor at the right side of the bed. Resident 6 stated, I need my urinal. CNA 9 took the urinal from the floor beside the bed and gave the urinal to Resident 6. CNA 9 took the urinal from Resident 6, disposed the urine, and placed the urinal on the floor next to Resident 6's bed.
On 2/12/19 at 9:40 a.m., during an interview, CNA 9 stated the urinal was placed on the floor because Resident 6 wanted the urinal to be placed on the floor not on the bedside table. CNA 9 stated it was not safe to place the urinal on the floor due to the urine spilling or spreading infection when Resident 6 used the urinal.
On 2/13/19 at 4:15 p.m., during an interview, the assistant director of nursing (ADON) stated the urinal should be place in a clean plastic bag and labeled with resident's name. The ADON stated staff should not place the urinal on the floor to prevent cross contamination.
Based on observation, interview, and record review, the facility failed to maintain an effective infection control program when:
1. Licensed vocational nurse (LVN) 8 did not clean a blood pressure (BP) cuff in between uses for Resident 57 and Resident 447.
2. Certified nursing assistant (CNA) 9 placed Resident 6's urinal on the floor.
3. Resident 75's used urinal was found hanging off the edge of the trash bin.
These failures had the potential risk for spreading infections to residents and staff through cross contamination and exposure to infectious organisms.
Findings:
1. On 2/13/19 at 8:08 a.m., during an observation in Resident 57's room, LVN 8 entered the room with a BP cuff and stethoscope. LVN 8 asked Resident 57 if she could take her BP. LVN 8 placed the BP cuff to the left upper arm and took the BP. After BP was taken, LVN 8 placed the BP cuff on the top of the medication cart (med cart). LVN 8 did not clean or sanitize the BP cuff after use.
On 2/13/19 at 8:27 a.m., during an observation in Resident 447's room, LVN 8 obtained the BP cuff from the med cart. LVN 8 placed the bp cuff on to Resident 447's left upper arm and took the BP. After BP was taken, LVN 8 placed the bp cuff on the top of the med cart. LVN 8 did not clean nor sanitize the BP cuff prior to checking Resident 447's BP. LVN 8 did not clean nor sanitize the BP cuff after use.
On 2/13/19 at 8:39 a.m., during an interview, LVN 8 stated she did not clean the BP cuff before use on Resident 57. LVN 8 stated she did not clean the BP cuff before using it on Resident 447. LVN 8 stated she should have cleaned the BP cuff between uses. LVN 8 stated not cleaning the BP cuff can spread infections of the skin.
On 2/15/19 at 7:54 a.m., during an interview, the assistant director of nursing (ADON) stated the licensed nurses and cnas should clean the BP cuff after each use. The ADON stated not cleaning the BP cuff was an infection control issue due to possible cross contamination.
Review of the facility document titled, Cleaning Schedule dated 10/16, indicated, .Equipment BP Cuffs .What to use Alcohol prep wipes (70%) or Sani-wipes .How to Clean and How Often .After each use/ prior to using device on another resident .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to honor two of 111 sampled residents (Resident 35 and Resident 30) food preference and dislikes when:
1. Resident 35 was served toasted wheat bread instead of white bread on her breakfast meal tray.
2. Resident 30 was served cream of wheat on his breakfast meal tray and was not offered an alternative of his choice.
These failures resulted in Resident 35 and Resident 30 feeling annoyed, their food dislikes not being accommodated, and placed Resident 35 and Resident 30 for potential weight loss from not eating foods they disliked.
Findings:
1. Review of Resident 35's clinical record, titled, Facesheet (a document containing resident profile information) indicated Resident 35 was admitted to the facility on [DATE]. Resident 35's Minimum Data Set (MDS) assessment (an evaluation of a resident's cognitive and functional status) dated 12/30/18, indicated a Brief Interview for Mental Status (BIMS)(assessment of cognitive status) score of 15 of 15 points which indicated Resident 35 was cognitively intact (pertaining to memory, recall and judgement).
On 2/12/19 at 7:52 a.m., during a concurrent observation and interview in Resident 35's room, Resident 35 sat in bed and was eating breakfast. Resident 35 had two pieces of toasted wheat bread on the breakfast tray. Resident 35 stated, I don't like wheat bread and toasted bread. I like white bread. I don't know why [facility staff] kept giving it to me when it's one of my dislikes. They do that all the time, it upsets me.
Review of Resident 35's breakfast meal slip [ticket] on 2/12/19 indicated, . Dislikes . Wheat Bread . Preferences . [NAME] Toast .
On 2/12/19 at 7:55 a.m., during a concurrent observation and interview in Resident 35's room, certified nursing assistant (CNA) 8 stated there was a toasted wheat bread on Resident 35's tray. CNA 8 picked up Resident 35's meal slip from the meal tray and reviewed Resident 35's dislikes. CNA 8 stated Resident 35 did not like wheat bread and should have received white bread based on her preference. CNA 8 stated the licensed nurse checked the tray before she served the tray to Resident 35. CNA 8 stated Resident 35 should have been given what she liked.
On 2/12/19 at 7:59 a.m., during a concurrent interview and record review, licensed vocational nurse (LVN) 3 stated Resident 35's dislikes was wheat bread. LVN 3 stated she checked the food tray before it got served to Resident 35 and should have not received the wheat bread. LVN 3 reviewed Resident 35's breakfast diet slip and stated, It's in her diet list that [Resident 35] does not like wheat bread, [Resident 35] should not have gotten the wheat bread and should be given white bread instead.
2. Review of Resident 30's clinical record, titled, facesheet indicated Resident 30 was admitted to the facility on [DATE]. Resident 30's MDS assessment dated [DATE], indicated a BIMS score of 13 of 15 points which indicated Resident 30 was cognitively intact.
On 2/12/19 at 8:05 a.m., during a concurrent observation and interview in Resident 30's room, Resident 30 sat in bed and was eating breakfast. Resident 30 had cream of wheat on the breakfast meal tray. Resident 30 stated, I don't like cream of wheat. I like oatmeal better. I don't know why I got this. Resident 30 stated the facility kept serving him cream of wheat all the time and he did not like it.
On 2/12/19 at 8:09 a.m., during a concurrent observation, interview and record review, the director of staff development (DSD) stated Resident 30 had cream of wheat on his breakfast tray. The DSD reviewed Resident 30's breakfast meal slip and stated one of Resident 30's dislike was cream of wheat. The DSD stated Resident 30 should not be served cream of wheat and his preference should be accommodated by the facility.
On 2/12/19 at 8:30 a.m., during a concurrent observation and interview in Resident 30's room, Resident 30 had cream of wheat on his breakfast tray. Resident 30 stated, I don't prefer to get [cream of wheat]. I prefer to get oatmeal.
On 2/12/19 at 9:25 a.m., during an interview, dietary aide (DA) 1 stated, The first person in the kitchen is the starter. The starter puts the [meal slip ticket], condiments and there is the cook's helper. The cook and the coffee person is the last one that puts the coffee and milk and checks if everything is in the tray. The first person announced the diet and what they like and don't like. It's a group effort to check if the resident got everything in the tray. DA 1 stated residents' food preferences should be accommodated by the facility.
On 2/12/19 at 9:35 a.m., during an interview, DA 2 stated, The first person is the starter who puts the condiments like butter, hot chocolate, silverware salt and pepper. The second person puts the fruits and cereals. The second person is the cook's helper and puts hot plate on the bottom. The third person is the cook who puts food in the hot plate and the fourth person is me, the coffee person. I put coffee, milk and make sure the resident gets what she likes and will not get what she does not like. DA 2 stated the wheat of cream served for Resident 30 looked similar to the oatmeal. DA 2 stated, I shake all of it. I don't like to keep opening the [food] tray because it makes the food cold sometimes. DA 2 stated, Residents' goes back and forth with what they want. Sometimes they want white bread, then wheat bread then the next day they change their mind again. DA 2 stated the meal slip should have been followed and Resident 35 and Resident 30's food preference should be accommodated by the facility. DA 2 stated Resident 35 and Resident 30 should have not received food they disliked.
On 2/12/19 at 10:55 a.m., during an interview, the director of nursing (DON) stated, Residents' likes are assessed during admission and their likes and dislikes constantly change. The DON stated the meal slip should have been followed by the dietary staff and residents' food preferences should be accommodated by the facility.
Review of the facility policy and procedure titled, Food and Dining Services dated 11/16, indicated, Purpose . Satisfy resident's tastes and appetites by determining and providing their food preferences at meals . 2. All food and dining services staff will be made aware of all preferences and food allergies. The food and dining services staff will avoid serving products that contribute to food allergies and make every attempt to meet the resident's food and preferences . Document all resident's food allergies and preferences on tray tickets .