Orchards At Tulare

Based on interview and record review, the facility failed to follow its own policy and procedure (P&P) for one of two sampled residents (Resident 1) when written request for Resident 1's clinical records was not provided in a timely manner. This failure resulted in violation of Resident 1's rights and not providing Resident 1's clinical records approximately 14 days after the request date.Findings:During a concurrent interview and record review on 3/9/26 at 10:34 a.m. with Administrator and Medical Records Personnel (MRP), MRP stated on 2/17/26 a written request for Resident 1's clinical record was received. MRP stated Resident 1's clinical record was not released until 3/9/26 (approximately 14 days after the request date). Administrator reviewed the facility's P&P titled, Release of Medical Records. Administrator confirmed the facility P&P was not followed when written request for Resident 1's clinical record was not released within 2 working days.During a review of facility's P&P titled, Release of Medical Records, dated 2025, the P&P indicated, Access Rights to Medical Information are as Follows: 1.The resident of his/her legal representative may receive a copy of his/her record within 2 working days after the request has been made.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure the ceiling vents (outlets that allow conditioned air to flow into a room) were clean and sanitary for ten of ten sampled residents' rooms (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]). This failure had the potential to result in the spread of respiratory illnesses to residents, staff, and visitors.Findings:During an observation on 3/3/26 at 10:14 a.m. in room [ROOM NUMBER], there were two ceiling vents with thick black dust like debris. During an observation on 3/3/26 at 10:17 a.m. in room [ROOM NUMBER], there was one ceiling vent with thick black dust like debris.During a concurrent observation and interview on 3/3/26 at 10:20 a.m. with Housekeeping (HSK) in room [ROOM NUMBER], HSK stated, The ceiling vents need to be cleaned, the vent has dirt on it, vents need to be cleaned, if not, it [dirt] falls on residents.During an observation on 3/3/26 at 10:30 a.m. in room [ROOM NUMBER], there was one ceiling vent with thick black dust like debris. During an observation on 3/3/26 at 10:41a.m. in room [ROOM NUMBER], there were two ceiling vents with thick black dust like debris. During an observation on 3/3/26 at 10:42 a.m. in room [ROOM NUMBER], there was one ceiling vent with thick black dust like debris. During a concurrent observation and interview on 3/3/26 at 10:45 a.m. with Housekeeping Supervisor (HSKS) in room [ROOM NUMBER], HSKS stated, Maintenance and myself are in charge of cleaning the vent, that vent hasn't been cleaned in days. We are supposed to clean, its dirty. All the stuff on the vents gets into their (residents) lungs if we don't clean them During an observation on 3/3/26 at 10:48 a.m. in room [ROOM NUMBER], there was one ceiling vent with thick black dust like debris. During an observation on 3/3/26 at 10:58 a.m. in room [ROOM NUMBER], there was one ceiling vent with black mold like debris. During an observation on 3/3/26 at 11:03 a.m. in room [ROOM NUMBER], there were two ceiling vents with thick black dust like debris. During an interview on 3/3/26 at 11:12 a.m. with Resident 1, Resident 1 stated, I have not seen housekeeping cleaning my room.During an observation on 3/3/26 at 11:17 a.m. in room [ROOM NUMBER], there were two ceiling vents with thick black dust like debris.During an interview on 3/3/26 at 11:18 a.m. with HSKS in room [ROOM NUMBER], HSKS stated they missed to clean the ceiling vents it shouldn't have been built up like that.During an interview on 3/3/26 at 11:25 a.m. with Maintenance Lead (MTL), MTL stated he doesn't do much cleaning, it's more of housekeeping and he doesn't clean them (ceiling vents) unless he's told to.During an interview on 3/3/26 at 11:40 a.m. with Infection Prevention (IP), IP stated she has not noticed issues with dust and has monthly meetings with housekeeping to maintain oversight. IP stated, It would be a respiratory concern with moldy or dusty vents. I have not implemented anything other than a deep cleaning schedule. During a review of the facility's Deep Clean Schedule (DCS), undated, the DCS indicated there were no instructions for cleaning ceiling vents.During a review of the facility's Room Rounds, Area of Observation (RRAO), undated, RRAO indicated there were no instructions for cleaning ceiling vents During a review of the facility's policy and procedure (P&P) titled, Routine Cleaning and Disinfection dated 2025, the P&P indicated Policy Explanation and Compliance Guidelines: 1. Routine cleaning and disinfection of frequently touched or visibly soiled surfaced will be performed in common areas, resident rooms, and at the time of discharge. 3.c. Clean from top to bottom (bring dirt from high levels down to floor levels). 4. Routine surface cleaning and disinfection will be conducted with a detailed focus on visibly soiled surfaces.

Based on interview and record review, the facility failed to provide supervision for one of two sampled residents (Resident 1) with impaired cognition (problem in ability to think, learn, remember, make decisions). This failure resulted in Resident 1 eloping (leaving facility unsupervised and without prior authorization) from the facility without staff being aware and had the potential for harm. Findings:During an interview on 2/26/26 at 12:06 p.m. with Registered Nurse (RN), RN stated on 2/7/26 at 10:38 a.m., she was made aware Resident 1 was outside the facility without supervision. RN stated Resident 1 was found in the parking lot across the street from the facility. RN stated Resident 1 was alert with impaired cognition, did not have an order to leave the facility, and was not safe to go outside the facility without supervision.During an interview on 2/26/26 at 12:19 p.m. with Infection Control Preventionist (ICP), ICP reviewed Resident 1's quarterly Minimum Data Set (MDS-a federally mandated resident assessment tool) dated 1/16/26, the MDS indicated Resident 1 had a BIMS (Brief Interview for Metal Status-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 0 (score range from 0-7 severe impairment.During an interview on 2/26/26 at 12:35 p.m. with Certified Nursing Assistant (CNA), CNA stated on 2/7/26 at approximately 10:30 a.m., he had opened the facility door for visitors to exit. CNA stated he did not recognize Resident 1 was standing among the visitors and had exited the facility when the door was open. CNA stated Resident 1 exited the facility without supervision. During a review of the facility 5-Day Follow-Up Report, the report indicated, On February 7, 2026, at approximately 10:38 AM, staff were notified that a male resident (Resident 1) was observed outside the facility in the hospital parking lot across the street. The resident had exited through the front entrance after a newly hired CNA opened the secured door for visitors and did not recognize the resident as a non-visitor.During a review of the facility's policy and procedures (P&P) titled, Elopements and Wandering Residents, undated, the P&P indicated, Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so.During a review of the facility's policy and procedures (P&P) titled, Accidents and Supervision, undated, the P&P indicated, 5. Supervision-Supervision is an intervention and a means of mitigating accident risk. The facility will provide adequate supervision to prevent accidents.

Based on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when:1. A glucometer (used to take residents blood sugar) was not sanitized after use for one of three sampled residents (Resident 1);2. Personal Protective Equipment (PPE-gown, gloves, mask, eye protection) was not worn when entering a droplet precaution (used to prevent the spread of germs transmitted through large respiratory droplets from coughing, sneezing, or talking) isolation room.These failures had the potential for spread and risk of infections to residents, visitors, and staff.Findings:1. During a concurrent observation and interview, on 11/24/25 at 12:22 p.m. with Licensed Vocational Nurse (LVN) 1, in Resident 1's room, LVN 1 placed a glucometer test strip in the glucometer, cleaned Resident 1's finger with alcohol, poked Resident 1's finger with the lancet (small, disposable, sterile needle used to prick the skin), placed a drop of blood on the test strip, reviewed the result, removed the test strip from the glucometer and placed the glucometer back in the medication cart. The glucometer was not sanitized prior to placing it in the medication cart. LVN 1 stated she forgot to sanitize the glucometer, and it should have been done after using the glucometer.During an interview on 11/24/25 at 1:53 p.m. with Infection Preventionist (IP), IP stated the glucometers were to be sanitized after each use.During a review of the facility's policy and procedure (P&P) titled Glucometer Disinfection dated 2025, the P&P indicated The facility will ensure blood glucometers will be cleaned and disinfected after each use and according to manufacturer's instructions for multi-resident use.2. During a concurrent observation and interview on 11/24/25 at 12:49 p.m. outside Resident 2's door, there was a sign on the door that indicated Droplet Precautions. Certified Nursing Assistant (CNA) 2 entered the room and picked up a food tray without putting PPE on. CNA 2 stated he was unaware of the type of precautions required when entering Resident 2's room.During an interview on 11/24/25 at 12:50 p.m. with Director of Staff Development (DSD), DSD stated Resident 2 was in droplet precautions and the staff should be wearing PPE when entering the room.During an interview on 11/24/25 at 12:54 p.m. with CNA 2, CNA 2 stated when he entered Resident 2's room, he should have had full PPE on including an N95 (a type of respirator that filters at least 95% of air particles), gown, gloves and eye protection.During an interview on 11/24/25 at 1:53 p.m. with IP, IP stated Resident 2 was on droplet precautions and when staff entered the room, they should be wearing a N95, gown, gloves and eye protection.During a review of the facility policy and procedure (P&P) titled, Transmission-Based (Isolation) Precautions dated 2025, the P&P indicated, Droplet Precautions.Intended to prevent transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions.Based upon the pathogen or clinical syndrome, if there is a risk of exposure of mucous membranes or substantial spraying or respiratory secretions is anticipated, gloves and gown as well as goggles (or face shield) should be worn.

Based on interview, and record review, the facility failed to follow its policy and procedure regarding Advance Directive (AD-a legal document indicating resident preference on end-of-life treatment decisions) for one of one sampled resident (Resident 446) were informed about their right to complete and AD or had evidence of declining to complete an AD. This failure had the potential for responsible parties and/or medical professionals not to honor resident healthcare wishes and to not provide appropriate treatment in the event of an emergency medical situation.
Findings:
During a concurrent interview and record review on 5/7/25 at 8:35 a.m. of Resident 446 medical record with Business Office Manager (BOM). BOM reviewed the medical record for Resident 446 and was unable to provide evidence of Resident 446 and/or responsible party were offered an opportunity to formulate or decline an AD.
During a review of the facility policy and procedure (P&P), titled Resident Rights Regarding Treatment and Advance Directive, dated 2025, indicated, Policy It is the policy of this facility to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate advance directive. Definitions: Advance directive is a written instruction, such as a living will or durable power of attorney for health care, recognized under state law (whether statutory or as recognized by the courts of the State), relating to the provision of health care when the individual is incapacitated. Policy Explanation and Compliance Guidelines: 1. On admission, the facility will determine if the resident has executed an advance directive, and if not, determine whether the resident would like to formulate an advance directive.

During an interview on 5/7/25 at 11:18 a.m. with Resident 32, Resident 32 stated a month ago her grey sweatshirt went missing. Resident 32 stated it was her favorite her daughter had given it to her. Resident 32 stated she reported the missing sweatshirt to housekeeping.
During an interview on 5/8/25 at 10:55 a.m. with Laundry, Laundry stated social services tells us to look for missing clothing items. Laundry stated I inform my boss of missing clothing now since there is no current social services staff.
During a review of the facility's policy and procedure (P&P) titled, Resident Personal Belongings, Undated, the P&P indicated, Policy: It is the policy of this facility to protect the resident's right to possess personal belongings .7. The facility will exercise reasonable care for the protection of the resident's property from loss or theft.
Based on observation, interview, and record review, the facility failed to ensure two of 16 sampled residents (Resident 32 and Resident 73), personal belongings were replaced within a timely manner once the items were reported loss. These failures resulted in Resident 32 and Resident 73 lost items not being replaced
During an interview on 5/6/25 at 10:33 a.m. with Resident 73, Resident 73 stated his watch had been missing since December 2024. Resident 73 stated he had reported his missing watch to the social worker. Resident 73 was told by the social worker that the facility will replace the missing watch. Resident 73 stated he was upset that his watch had been missing, and the facility had not replaced the watch.
During a review of Resident 73's admission Record, (AR) dated 5/7/25, the AR indicated Resident 73's admission date was 9/9/24.
During a review of Resident 73's Minimum Data Set, (MDS - a federally mandated resident assessment tool) dated 3/14/25, the MDS indicated Resident 73 had a (Brief Interview for Mental Status - an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 15 (score of 13-15 means cognitively intact).
During a review of Resident 73's Inventory List, (IL) dated 9/9/24, the IL indicated jewelry, one watch.
During an interview on 5/7/25 at 10:30 a.m. with Acting Activities Director (AAD), AAD stated when she receives a theft or loss report, she will go speak to the resident. AAD stated the facility will replace missing items within seven days.
During an interview on 5/7/25 at 10:36 a.m. with Administrator, Administrator stated her expectation from staff on loss or theft are to report to AAD, fill out the theft/loss form, and replace Resident 73's missing item within seven days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a Significant Change in Status MDS Assessment (MDS-a federally mandated resident assessment tool; SCSA- a comprehensive assessment completed within 14 days of the identification of a status change) was completed for one of one sampled resident (Resident 68) when Resident 68 had a major decline in two or more MDS areas as evidenced by unplanned significant weight loss and the development of a new wound. This failure had the potential for Resident 68 to have unmet care needs.
Findings:
During a concurrent interview and record review on 05/08/25 at 11:14 a.m. with MDS Coordinator (MDSC), MDSC reviewed Resident 68's electronic health record (EHR). MDSC stated she should have completed a significant change of status MDS at the same time she had completed a quarterly MDS on 2/26/25 as Resident 68 had major decline in two MDS care areas which were significant weight loss not on prescribed weight-loss regimen and a new wound that triggered on the quarterly MDS.
During a review of Resident 68's quarterly MDS, dated [DATE], the quarterly MDS indicated, D 1. Number of Stage 4 pressure ulcers: 1, D 2. Number of these Stage 4 pressure ulcers that were present upon admission/reentry: 1.
During a review of Resident 68's quarterly MDS, dated [DATE], the quarterly MDS indicated, D 1. Number of Stage 4 pressure ulcers: 3, D 2. Number of these Stage 4 pressure ulcers that were present upon admission/reentry: 2.
During a review of Resident 68's RD [Registered Dietitian]/IDT [interdisciplinary team] Weight [wt] Variance Meeting [mtg] (Wt Mtg), dated 12/31/24, the Wt Mtg indicated, Wt: 85# (pounds). Wt Change: -23# (21.3%[percent loss of body weight]) x [for] 3 months,.Prostat [supplement to increase protein and calories], MVM [multivitamin with minerals], Skin: Stage 4 [pressure injury with full-thickness skin and tissue loss] to sacrum [bone in the lower portion of the spine], unstageable [pressure injury with covered full-thickness skin and tissue loss] to R [right] leg, trauma wound to R leg, skin tear to R forearm, Resident sent to acute [hospital] (12/14/2024) for syncope [fainting] and readmitted (12/16/2024) s/p [status post] IV [intravenous] hydration. Resident with decreased appetite, new wound, and s/p antibiotic tx [therapy] for R leg trauma wound.
During a review of Resident 68's Weights and Vitals Summary (WVS), the WVS indicated, on 08/23/2024, Resident 68 weighed 113 lbs. On 02/17/2025, Resident 68 weighed 87 pounds which is a -23.01 % Loss [of body weight] in last 6 months.
During a concurrent interview and record review on 05/06/25 at 2:44 p.m. with RD, Resident 68's Nutrition Evaluation (NE), dated 8/27/2024 was reviewed. The NE indicated relevant diagnoses.moderate protein-calorie malnutrition, adult failure to thrive [a process of physical and psychological decline], pressure ulcer. Diet order: Regular diet, Regular texture, Height: 59 [inches] Date: 8/23/24, Weight: 113 pounds (lbs) Date: 8/26/24, Appearance/Skin full thickness unstageable (pressure injury covered full-thickness skin and tissue loss to coccyx [tailbone], wound to R lateral leg, Nutrition Needs Estimate: 1,541 calories daily, Protein (Pro): 77 grams (g) daily, Fluids: 1,541 ml (milliliter- measurement of capacity), Discussed importance of meeting EEN [estimated energy needs] and hydration needs for wound healing. Resident verbalized understanding. Will continue to monitor weight x 4 weeks. Increased nutrient needs r/t [related to] wound healing, RD recommends: Prosat 30 ml BID [two times a day for increased calories of 200 and 30 g of pro]. Goals: 1) Will not have worsening in skin condition or new skin breakdown to the extent possible. 2) Will maintain adequate nutritional status as evidenced by stable. 3) Will not exhibit s/s (signs/symptoms) of dehydration.
During a review of Resident 68's RD/IDT Weight Variance Meeting (Wt Mtg), dated 2/6/25, the Wt Mtg indicated Resident 68 was on a fortified diet [added 500 calories], Prostat 60 ml BID [added 400 calories and 60 g pro], on appetite stimulant indicative of not being on a prescribed weight-loss regimen.
During a review of the facility's policy and procedure (P&P) titled, MDS 3.0 Completion, dated 2022, the P&P indicated, Policy: Residents are assessed, using a comprehensive assessment process, in order to identify care needs and to develop an interdisciplinary care plan. Policy Explanation and Compliance Guidelines: d. Significant change is a major decline or improvement in a resident's status that: (1) will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting, if a decline); 2) impacts more than one area of the resident's health status, and (3) requires interdisciplinary review and/or revision of the care plan. Quarterly Assessment - completed using an ARD [Assessment Reference Date] no > [greater than] 92 days from the most recent prior quarterly or comprehensive assessment (counting ARD to ARD). The R.N. [Registered Nurse] Coordinator signs, dates, and attests (in section Z0500A) to timely completion of the RAI [Resident Assessment Instrument], once all disciplines have completed their sections.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** During a review of Resident 68's Resident Matrix (RM), dated 5/5/25, the RM was reviewed. The RM did not have a check mark in the box under Excessive Weight Loss Without Prescribed Weight Loss Program.
During a concurrent interview and record review on 05/08/25 at 11:38 a.m. with MDS Coordinator (MDSC), Resident 68's quarterly Minimum Data Set (MDS-a federally mandated resident assessment tool), dated 2/26/25, was reviewed. The quarterly MDS, with Assessment Reference Date (ARD) dated 2/26/25 indicated, K0200 B. Weight (in pounds) - 87, section K0300. Weight Loss; Loss of 5% [percent] or more in the last month or loss of 10% or more in last 6 months was coded as 1. Yes, on prescribed weight-loss regimen. MDSC stated the section titled K0300. Weight Loss; Loss of 5% or more in the last month or loss of 10% or more in last 6 months was not coded accurately, as it should have been coded as 2. Yes, not on prescribed weight-loss regimen, as the facility was not intentionally trying to get Resident 68 to lose weight.
During a review of Resident 68's Weights and Vitals Summary (WVS), the WVS indicated on 08/23/2024, Resident 68 weighed 113 pounds (lbs) On 02/17/2025, Resident 68 weighed 87 lbs which is a -23.01 % loss of body weight in last 6 months.
During a concurrent interview and record review on 05/06/25 at 2:44 p.m. with Registered Dietitian (RD), Resident 68's Nutrition Evaluation (NE), dated 8/27/2024 was reviewed. The NE indicated relevant diagnoses.moderate protein-calorie malnutrition, adult failure to thrive (a process of physical and psychological decline), pressure ulcer. Diet order: Regular diet, Regular texture, Height: 59 [inches], dated 8/23/24 and weight of 113 lbs dated: 8/26/24. Appearance/skin full thickness unstageable (pressure injury covered full-thickness skin and tissue loss to coccyx (tailbone), wound to R (right) lateral leg, nutrition needs estimate: 1,541 calories daily, protein (pro): 77 grams (g) daily and fluids: 1,541 ml (milliliter-measurement of capacity). The NE indicated RD, Discussed importance of meeting EEN (estimated energy needs) and hydration needs for wound healing. Resident verbalized understanding. Will continue to monitor weight x 4 weeks. Increased nutrient needs related to wound healing, RD recommends: Prosat [nutrition supplement; increase of 200 calories; 30 g of pro] 30 ml BID (two times a day). Goals: 1) Will not have worsening in skin condition or new skin breakdown to the extent possible. 2) Will maintain adequate nutritional status as evidenced by stable. 3) Will not exhibit s/s [signs/symptoms] of dehydration.
During a review of Resident 68's RD/IDT Weight Variance Meeting (Wt Mtg), dated 2/6/25, the Wt Mtg indicated Resident 68 was on a fortified diet [added 500 calories], Prostat 60 ml BID [added 400 calories and 60 g pro], on appetite stimulant indicative of not being on a prescribed weight-loss regimen.
During a concurrent interview and record review on 05/08/25 at 11:45 a.m. with MDSC, Resident 68's RM, dated 5/5/25, was reviewed. MDSC stated Resident 68's RM was not accurate as it did not have a checkmark for Excessive Weight Loss Without Prescribed Weight Loss Program and should have. MDSC stated the error was made on Resident 68's RM because the quarterly MDS, dated [DATE], was not accurate.
During a review of the facility's policy and procedure (P&P) titled, MDS 3.0 Completion, dated 2022, the P&P indicated, Policy: Residents are assessed, using a comprehensive assessment process, in order to identify care needs and to develop an interdisciplinary care plan. Policy Explanation and Compliance Guidelines: Quarterly Assessment - completed using an ARD [Assessment Reference Date] no > [greater than] 92 days from the most recent prior quarterly or comprehensive assessment (counting ARD to ARD). The R.N. [Registered Nurse] Coordinator signs, dates, and attests (in section Z0500A) to timely completion of the RAI [Resident Assessment Instrument], once all disciplines have completed their sections.
Based on observation, interview, and record review, the facility failed to ensure the Minimum Data Set (MDS-a federally mandated resident assessment tool) Matrix was accurate and up to date for three of eight sampled residents (Resident 1, Resident 23 and Resident 68). This failure resulted in the documentation of an inaccurate assessment and an inaccurate quarterly MDS for Resident 68.
Findings:
During a review of the facility's Resident Matrix, (RM) dated 5/5/25, the RM indicated, Resident 1 listed anticoagulant (medication used to help prevent blood clots from forming or growing) and Resident 23 listed antibiotic.
During an interview on 5/5/25 at 10:16 a.m. with Resident 1, Resident 1 stated he is not currently taking any anticoagulant medications. Resident 1 stated he stopped taking anticoagulant medications this past January.
During a review of Resident 1's admission Record (AR), dated 5/7/25, the AR indicated Resident 1's initial admission date was 11/22/24.
During a review of Resident 1's MDS dated [DATE], the MDS indicated Resident 1 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 13 (score of 13-15 means cognitively intact).
During a concurrent interview and record review on 5/8/25 at 10:28 a.m. with Minimum Data Set Coordinator (MDSC), Resident 1's Discontinue Order, DO dated 12/6/24 was reviewed. The DO indicated, Order Summary: Eliquis Oral Tablet 5 MG [milligram] (Apixaban) Discontinue Dated: 12/6/2024 Reason for Discontinue: D/C [discontinue] per MD [Doctor of Medicine] orders. MDSC stated she had refreshed the matrix on 5/5/25. MDSC stated Resident 1 is currently not on an anticoagulant medication.
During an interview on 5/5/25 at 10:31 a.m. with Resident 23, Resident 23 stated he is not currently taking antibiotics.
During a review of Resident 23's AR, dated 5/7/25, the AR indicated Resident 23's initial admission date was 2/25/25.
During a review of Resident 23's MDS dated [DATE], the MDS indicated Resident 23 had a BIMS score of 15.
During a concurrent interview and record review on 5/8/25 at 10:36 a.m. with MDSC, Resident 23's DO dated 2/25/25 was reviewed. The DO indicated, Order Summary [OS]: ceftazidime [medication used to treat infections] Intravenous [IV-administered directly into a vein] Solution .Discontinue Date: 2/25/2025. MDSC stated Resident 23 was admitted in the facility with IV antibiotic therapy. MDSC stated Resident 23 was on ceftazadine and was discontinued on 3/18/25.
During an interview on 5/8/25 at 10:39 a.m. with MDSC, MDSC stated she generally tried to keep the matrix up to date on Fridays. MDSC stated she can manually update the matrix. MDSC stated she didn't get a chance to update the Matrix and she should have updated the Matrix.
During an interview on 5/8/25 at 10:43 a.m. with Administrator, Administrator stated her expectations for the MDSC is for the Matrix to be updated on Fridays.
During a review of the facility's RAI Coordinator - Job Description, RAI Coordinator - Job Description dated 2020, the RAI Coordinator - Job Description indicated, Major Duties and Responsibilities: Accurate completion of all MDS assessments and any supporting assessments or clinical documentation.
A policy was requested and none were provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide quality care to one of one sampled resident (Resident 25) when:
1. Resident 25 had a chocking episode that was not immediately identified and addressed by nursing staff who were present in the dining room at the time of occurance.
2. A comprehensive (complete) assessment was not completed for Resident 25 after a chocking episode and delegation (assigning a task) of monitoring Resident 25 for safety was given to nonnursing staff position titled Hospitality Aid (HA).
3. Education was not provided to a family member who routinely fed Resident 25 who was on aspiration precautions (preventive measures taken to reduce the risk of accidental inhalation of food, liquid, or other substances into the lungs) to ensure swallow strategies, as assessed by a Speech Therapist (ST), was implemented.
4. Resident 25's thickened liquids (to help individuals with swallowing difficulties based on individualized assessment) order was not followed.
These failures resulted in Resident 25 having unidentified needs and improper assessment during an episode of chocking with potential for aspiration or death.
Findings:
1. During a review of Resident 25's facesheet, the facesheet indicated Resident 25 was admitted to the facility on [DATE] with diagnosis of aphasia (a language disorder that impairs a person's ability to understand and verbalize) and Alzheimer's (a brain disorder that impairs thinking and memory skills) disease.
During a review of Resident 25's Minimum Data Set (MDS), dated 5/5/25, the MDS indicated Section C: BIMS [Brief Interview for Mental Status-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident] score 0 [indicates severe cognitive impairment].
During an observation on 05/05/25 at 1:04 p.m. in the dining room, Resident 25 took a bite of food and began coughing continuously and then vomited into plastic red plate cover. Family Member (FM) 1, who was sitting next to Resident 25, flagged a nurse to check on Resident 25 after she vomited. Director of Staff Development (DSD), who was present in the dining room while Resident 25 was coughing, responded to FM 1 by going over to Resident 25. FM 1 requested Resident 25 be taken back to Resident 25's room. As Resident 25 was being wheeled out of the dining room by DSD, Resident 25 was still coughing.
During an interview on 05/05/25 at 1:19 p.m. with the Assistant Director of Nursing (ADON), ADON stated she was in the dining room sitting in front of Resident 25 but was assisting another resident with eating. ADON stated she saw Resident 25 being wheeled out of the dining room, but other than that she did not hear anything. ADON stated DSD told her Resident 25 had vomited and DSD assessed her.
During an interview on 05/07/25 at 10:18 a.m. with ADON, ADON stated the facility assigned DSD and Licensed Vocational Nurse (LVN) 3 to provide general supervision of residents eating in the dining room for emergent (emergency) reasons. ADON stated DSD and LVN 3 were present in the dining room and should have immediately attended to Resident 25 when she was coughing and vomiting, and that did not happen.
During an interview on 05/07/25 at 11:15 a.m. with DSD, DSD stated he was aware of his responsibility to supervise during mealtimes.
During a review of American Heart Association Basic Life Support (BLS) training, the BLS training indicated, The AHA's BLS course trains participants to promptly recognize several life-threatening emergencies.
During a review of DSD's employee training, DSD was issued Basic Life Support (BLS) on 3/20/24 with an expiration date of 03/2026.
During a review of the facility's policy and procedure (P&P) titled, Meal Supervision and Assistance, the P&P indicated .adequate supervision and assistance to prevent accidents.
2. a) During a concurrent observation and interview on 05/05/25 at 1:13 p.m. with DSD, Resident 25 was taken back to her room by DSD after coughing/choking and vomited while eating lunch in the dining room. DSD stated, FM 1 stated Resident 25 was vomiting which was why FM 1 called me over. DSD stated he took Resident 25 back to her room and performed an assessment, which consisted of palpating (examination by touch) Resident 25's stomach in which Resident 25 did not grimace (expression) in pain. DSD stated Resident 25 was left in her room sitting in her wheelchair.
During an observation on 05/05/25 at 1:18 p.m. Resident 25 was sitting in her wheelchair in her room next to her bed.
During an interview on 05/07/25 at 10:48 a.m. with ADON, ADON stated an appropriate resident assessment for someone who was choking should be assessing how the resident looks, are there signs and symptoms of aspiration, assessment of the way a resident was breathing, any respiratory (lung) distress, and any abdominal (stomach) pain. ADON stated palpating the abdomen only was not an accurate assessment to have completed on Resident 25 after the coughing and vomiting episode.
During an interview on 05/07/25 at 11:01 a.m. with Licensed Vocational Nuse (LVN) 2, LVN 2 stated DSD said Resident 25 was observed to have one episode of coughing and one episode of vomiting in the dining room. LVN 2 stated DSD, and I laid Resident 25 in her bed (bed was at a 30-degree angle), and completed an assessment. LVN 2 stated the assessment included an assessment of G-Tube (gastrostomy tube-a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) placement and residual (remaining or left over contents) and Resident 25's blood pressure was taken.
During an interview on 05/07/25 at 11:26 a.m. with ADON, ADON stated LVN 2's assessment was not appropriate for Resident 25. ADON stated LVN 2 should have assessed respiratory distress (danger), signs and symptoms of continual coughing, obstruction (blockage) of airway, and completed an oral cavity (mouth) assessment. ADON stated the lack of proper assessment was not a safe practice, and the staff needed more education on focused assessments. ADON stated when a proper assessment was not completed there could be signs and symptoms that were missed, therefore potentially not addressed, which could cause the patient to have further distress.
During a review of Resident 25's Change in Condition Evaluation (COC), dated 5/5/25, the COC indicated Resident 25, observed having x1 episode of vomiting and x1 episode of cough. Resident removed from dining and taken back to room, for further assessment.
During a review of the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status, dated 2/2021, the P&P indicated if a significant change in the resident's physical or mental condition occurs, a comprehensive assessment of the resident's condition will be conducted.
b) During an interview on 05/05/25 at 1:13 p.m. with DSD, DSD stated he communicated to the HA to watch Resident 25 due to coughing and vomiting. DSD stated he did not mention the incident to anyone other than HA.
During an interview on 05/06/25 at 10:56 a.m. with DSD, DSD stated the Hospitality Aid duties are to stay inside the room for redirection (to direct to a different place or purpose) of residents.
During an interview on 5/6/25 at 12:47 p.m. with HA, HA stated his job was to watch all three residents in the room because those residents were at a higher risk of falling. HA stated no credentials (qualifications) are required for this position.
During an interview on 05/07/25 at 10:48 a.m. with ADON, ADON stated the Hospitality Aid was not a licensed CNA (certified nursing assistant); therefore, they could only monitor for safety. ADON stated HAs cannot assist in feeding or providing care to residents. ADON stated DSD should have reported to Resident 25's primary nurse. ADON stated appropriate delegation to the HA was for risk of falls or in case Resident 25 was in severe distress, the HA could call for help; however, in this situation the seriousness was not falling, the seriousness of the event was the choking, therefore this was not an appropriate delegation.
During a review of Job description for Hospitality Aide (JDHA), the JDHA indicated The primary purpose of your job position is the provision of services to the residents. At no time are you to provide direct care to the residents.
3. During an observation on 5/6/25 at 1:02 p.m. in the dining room, Resident 25 was sitting in a wheelchair at a dining table with Family Member (FM) 1 to the right. Resident 25 was served a lunch meal with pureed diet; red drink (appeared to be thin liquid). FM 1 started feeding Resident 25 large bites of pureed food on a spoon. Resident 25 took several sips of red colored drink after each bite. Resident 25 was still chewing when FM 1 gave Resident 25 another bite.
During an interview on 5/6/25 at 1:13 p.m. with DSD, DSD stated the expectation was to educate and teach Resident 25's family member who routinely fed Resident 25 about her diet and feeding skills to maintain consistency (performing in a similar way) when family helps feed Resident 25.
During a concurrent interview and record review on 05/07/25 at 10:18 a.m. with ADON, Resident 25's care plan titled Resident has declined in: swallowing function resulting to risk in aspiration, dated 1/2025 was reviewed. The care plan indicated interventions Aspiration precautions: slow rate, small bite size, chin tuck, double swallow, position upright as close to 90 degrees as possible. ADON stated she was aware Resident 25 needed to follow aspiration precautions listed on the care plan. ADON stated the only intervention she would not be able to visualize was double swallowing. ADON stated she could visualize position, chin tuck (ADON demonstrated chin tuck by moving her chin down to her chest), and small bites. ADON stated FM 1 does not have training regarding feeding precautions for Resident 25 and should have been trained.
During an interview on 05/07/25 at 10:48 a.m. with ADON, ADON stated the way FM 1 was feeding Resident 25 was not appropriate based on observation of FM 1 feeding Resident 25 on 05/06/25. ADON stated this meant [name of FM 1] was not educated or did not understand the education provided to properly feed Resident 25 per Resident 25's Care Plan and aspiration precautions.
During an interview on 05/07/25 at 10:46 a.m. with Minimum data Set Coordinator (MDSC), the MDSC stated a BIMS (Brief Interview for Mental Status) of zero, as listed for Resident 25, meant resident could not respond to the questions asked. MDSC stated when I spoke with Resident 25, she could verbalize (express) some needs but, at the time of the interview Resident 25 did not give a response to the questions. MDSC stated Resident 25 was more verbal on some days and other days Resident 25 was non-verbal.
During an interview on 5/7/25 at 11:01 a.m. with LVN 2, LVN 2 stated FM 1 feeds Resident 25 100% of the time.
During a review of Resident 25's Order Details (OD), dated 1/14/25, the OD: indicated ST [speech therapy] eval [evaluation] and tx [treatment] as indicated.
During a concurrent interview and record review on 05/07/25 at 04:11 p.m. with ST, Resident 25's Care plan titled Resident has declined in: swallowing function resulting to risk in aspiration, dated 1/2025 was reviewed. The care plan indicated interventions Aspirations precautions: slow rate, small bite size, chin tuck, double swallow, position upright close to 90 degrees as possible. ST 1 stated this care plan was created by me and the interventions are compensatory (making up for a loss), the chin tuck protects the airway. ST stated diet recommendation was puree at this time food trials were being completed for Resident 25. ST stated the care plan indicated what was provided during treatments which included honey-thick liquids. ST stated Resident 25 was discharged on 2/11/25 from speech therapy because Resident 25 was sent to the hospital for vomiting and G-Tube dislodgement. ST stated Resident 25 never came back to speech therapy after returning from the hospital.
During a concurrent interview and record review on 05/07/25 at 04:11 p.m. with ST, Resident 25's Speech Therapy Note (STN) dated 1/21/25 was reviewed. The STN indicated PT (patient)/caregiver ed (educated) to ensure safety of intake and oral hygiene to reduce risks for bateria [sic] in the lungs and prevention of bacterial pneumonia. ST stated a caregiver was anyone who was caring for the resident, this included family and staff. ST stated I am not sure if her family member or Certified Nursing Assistant (CNA) was trained. ST stated for Resident 25 I educated Resident 25 to the best of her ability and understanding. ST stated because of Resident 25's diagnosis of aphasia ST had to model a lot of the education provided to Resident 25. ST stated if Resident 25 was still in speech therapy she would be responsible for training family on feeding Resident 25 appropriately. ST stated her expectations were the interventions should have continued for Resident 25's safety.
4. During an observation on 5/6/25 at 1:02 p.m. in the dining room, Resident 25 was served her lunch meal tray. Resident 25 was observed drinking a red colored liquid that appeared to be a thin liquid.
During an interview on 5/6/25 at 1:15 p.m. with FM 1, FM 1 stated the red liquid was thin, not thick like the white drink she also was served.
During an interview on 5/6/25 at 1:18 p.m. with Dietary Aide (DA), DA stated she prepared thickened punch and placed punch on meal trays.
During a review of Resident 25's Order Summary (OS), dated 4/10/25, the OS indicated CCHO [diabetic diet]/NAS [no added salt] diet Puree texture, Nectar consistency, Dietary oral gratification PO [by mouth] diet small portion.
During a review of Resident 25's Meal Ticket (MT), the MT indicated Resident 25 had nectar thickened liquids.
During a review of the facility's policy and procedure (P&P) titled, Serving a Meal, the P&P indicated diets should be served in accordance with the physician orders.
During a review of the facility's P&P titled, Therapeutic Diet Orders, the P&P indicated The facility provides all residents with foods in the appropriate form and/or the appropriate nutritive content as prescribed by a physician, and/or assessed by the interdisciplinary team to support the resident's treatment/plan of care, in accordance with his/her goals and preferences.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to:
1. Ensure the Registered Dietitian (RD) accurately and comprehensively assessed nutritional status for one of one sampled resident (Resident 68) in accordance with standard of practice and facility policy and procedure (P&P) related to lack of re-assessing Resident 68's daily calorie, protein and fluid needs after a significant change in condition related to pressure injury and significant unplanned weight loss.
2. Effectively monitor nutrition interventions when facility did not document quantity consumed of oral nutrition supplement (ONS) provided on meal trays for one of one sampled resident (Resident 68) and did not convene a follow-up IDT (interdisciplinary team) weight variance meeting to evaluate effectiveness of a ONS that was provided to address Resident 68's significant unplanned weight loss until a month after the ONS was initiated, during which time Resident 68 continued to have further significant weight loss. In addition, in general, the facility was implementing HN (house nourishment) shake as an equivalent choice to Mightyshakes in which the calories provided were not nutritionally equivalent. Further, the facility lacked a variety of nutrition supplements to offer to residents, in general, who were assessed as needing additional calories and/or protein, or who may want to opt for a different ONS after prolonged use of the same one, including for Resident 68. (Cross Refer F842)
3. Effectively monitor, evaluate and identify, inadequate fluid intake during which time Resident 68 had increased fluid needs due to multiple pressure injuries, including Stage 4 (Full-thickness skin and tissue loss) and apply relevant approaches such as obtaining Resident 68's beverage preferences to help Resident 68 improve fluid intake. (Cross Refer F807)
Facility failure to identify gaps in the systematic interdisciplinary process to include identifying, assessing and monitoring resident's food and fluid intake (hydration) in accordance with standard of practice and facility P&P had the potential to negatively contribute to a symptom, illness, or decline in nutrition and medical status for Resident 68.
Findings:
1. During a concurrent observation and interview on 5/05/25 at 1:00 p.m. with Certified Nursing Assistant (CNA) 2 in Resident 68's room, Resident 68 was sitting up in bed. CNA 2 was encouraging Resident 68 to eat. Resident 68 stated she received a supplemental shake (to increase calories and protein) but did not like it so she did not drink it.
During a concurrent interview and record review on 05/06/25 at 2:44 p.m. with RD, Resident 68's Nutrition Evaluation (NE), dated 8/27/2024 was reviewed. The NE indicated, Relevant Diagnoses.moderate protein-calorie malnutrition, iron deficiency anemia, adult failure to thrive.esophageal reflux disease.urinary tract infection, pressure ulcer of sacral [bottom of the spine] region, unspecified stage. Labs from acute: (8/12) Hgb [hemoglobin; a red protein responsible for transporting oxygen] 8.4L [liter; a metric unit of capacity], Hct [hematocrit; the percentage of red blood cells in your blood] 26.8 L, Na [sodium] 4.1, Cr [Creatinine] 0.50 [a waste product produced from muscle metabolism], BUN [Blood Urea Nitrogen; a waste product produced in the liver when proteins are broken down] 7 [indicating healthy kidney function], diet order: Regular diet, Regular texture, Supplement Order: Ferrous Sulfate [a form of the mineral iron].Height: 59 [inches] Date: 8/23/24, Weight: 113 pounds (lbs) Date: 8/26/24, Appearance/Skin full thickness unstageable [covered full-thickness skin and tissue loss] to coccyx [tailbone], wound to R [right] lateral leg, appears hydrated, Nutrition Needs Estimate: Kcal: 1,541 kcal [calories] (30kcal/[per] kg [kilogram; A unit of mass in the metric system, equal to one thousand grams]), Protein [pro]: 77 gm [grams] (1.5 gm/kg), Fluids: 1,541 ml [milliliter; unit of capacity] (30 ml/kg), Intake: 50-100%, Adequacy of Intake: adequate,.UBW [usual body weight]: 113# [lbs].Discussed importance of meeting EEN [estimated energy needs] and hydration needs for wound healing. Resident verbalized understanding. Will continue to monitor weight x 4 weeks. Increased nutrient needs r/t [related to] wound healing AEB [as exhibited by] full thickness unstageable to coccyx, wound to R lateral leg. RD recommends: 1) Vit C 500mg BID [two times a day] 2) Prostat [nutrition supplement to increase calories and protein] 30 ml BID 3) MVI [multivitamin] QD [every day] RD.Goals: 1) Will not have worsening in skin condition or new skin breakdown to the extent possible. 2) Will maintain adequate nutritional status as evidenced by stable. 3) Will not exhibit s/s [signs/symptoms] of dehydration. RD stated her nutrition recommendations were ordered by the physician the following day.
During a review of Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline (CPG), dated 2019, the CPG indicated, In healthy people, water/fluid intake should be approximately 30 mL/kg body weight/day or 1 mL/kcalorie/day.
During a review of Resident 68's Progress Notes (PN), dated 9/8/24, 9/16/24, and 9/24/24, the PN indicated Resident 68 refused weekly weight measurements despite risks vs benefits of weight explained.
During a review of Resident 68's History and Physical (H&P), dated 10/14/24, the H&P indicated, Resident 68 had the mental capacity to make medical decisions.
During a concurrent interview and record review on 05/06/25 at 2:50 p.m. with RD, Resident 68's RD/IDT [interdisciplinary] Weight [wt] Variance Meeting [mtg] (Wt Mtg), dated 10/3/24 was reviewed. The Wt Mtg indicated Resident 68 had a 7.7% (percent) loss of body weight in one month. RD stated Resident 68 was eating 76-100% of meals and there was a stage 4 to sacrum, unstageable to R leg. RD stated Resident 68 was placed on a fortified diet that provided an additional 500 calories a day and double protein diet, in addition to Prostat 30 ml BID she had been receiving.
During an interview on 05/06/25 at 2:55 p.m. with RD, RD stated it was standard of practice to reassess daily calorie, protein and fluid needs after a significant change in condition, whether it was during this IDT weight meeting or any other nutrition assessment. RD stated she did not do that for Resident 68 after she had significant weight loss. Although there was documentation of food intake [76-100% of meals] there lacked an evaluation as to whether the food intake met Resident 68's caloric needs as there was no accurate, relevant nutrition assessment of her needs after a significant change of condition. Lack of a current nutrition assessment posed a barrier in determining whether Resident 68's nutrition plan of care needed to be updated and revised. The RD and/or RD/IDT Wt Mtg note lacked indication that Resident 68's Monitor Fluid Intake logs (CNA documentation of Resident 68's fluid intake from meal trays) were reviewed which may lead to early identification of insufficient fluid intake to help prevent and/or minimize complications. There lacked documentation to indicate a review and evaluation of potential sources of fluid loss to include review of IDT Weight/Nutrition/Skin Progress Note, dated 9/3/24, and 9/5/24 that noted moderate serous drainage (watery, clear, or slightly yellow/tan/pink fluid that has separated from the blood and presents as drainage) from the Stage 4 pressure wound to sacrum and light serous drainage from the R leg, if chronic and prolonged, may require re-assessing for an additional amount of fluid per kilogram of body weight for Resident 68. Without an accurate and comprehensive re-assessment of fluid needs after a significant change of condition, there was not a mechanism to evaluate fluid intake as compared to assessed needs in order to identify and communicate quantity of ml of fluids not being consumed by Resident 68 to bring to the attention of IDT and/or physician in a timely manner, so MD could determine whether additional tests or interventions may have been warranted.
During a review of Advances in Skin & Wound Care (WC), dated 2020, the WC indicated those with draining wounds require additional fluids/water to replace lost fluid, and should be monitored as dehydration could be a factor in weight loss.
During a review of the facility's P&P titled, Nutritional Management, dated 1/2025, the P&P indicated, Compliance Guidelines: A comprehensive nutritional assessment will be completed by a dietitian.upon significant change in condition.Components of the assessment may include, but are not limited to:.Food and fluid intake, Evidence of fluid loss.Evaluation/analysis: The dietitian shall use data gathered from the nutritional assessment to estimate the resident's calorie, nutrient, and fluid needs and whether intake is adequate to meet those needs. Current standards of practice/formulas are used in calculating these estimates.
During a review of Resident 68's PN, dated 10/7/24 and 10/14/24, the PN indicated Resident 68 refused weekly weight measurements despite risks vs benefits of weight explained.
During a concurrent interview and record review on 05/06/25 at 3:00 p.m. with RD, Resident 68's Wt Mtg, dated 11/6/24, was reviewed. RD stated due to Resident 68's refusals to have her weight taken the facility did not become aware of her significant unplanned weight loss of 10.2% of body weight until she allowed her weight to be taken on 11/4/24 and she was 97 lbs. The Wt Mtg note, dated 11/6/24, indicated, Po intake: 51-75%, Diet: Fortified diet, Double Protein diet.Skin: stage 4 to sacrum, unstageable to R leg, Prior Interventions: fortified diet, double protein, wound supplements [Prostat 30 ml BID].RD has explained importance of meeting EEN for wound healing and preventing weight loss. Family brings resident outside favorite food. CDM [Certified Dietary Manager; Dietary Supervisor (DS)] updated food preferences. Resident in agreement to add HN [house nourishment] w [with]/meals and ice cream. IDT Recommendations: add HN [4 oz] w/meals and weekly weights.
During a concurrent interview and record review on 05/06/25 at 3:05 p.m. with RD, Resident 68's Wt Mtg, dated 12/5/24, was reviewed. The Wt Mtg note indicated Resident 68 weighed 90 lbs which was 7.2% further unplanned significant weight loss in a month and was an 18 lb wt loss (16.7% loss of body weight) over 3 months, po intake was 51-75% overall of breakfast, lunch and dinner meals, and skin continued with stage 4 to sacrum, unstageable to R leg. The Wt Mtg indicated during the time since the previous Wt Mtg, Prostat had been increased from 30 ml BID to 60 ml BID and an antidepressant medication was started on 11/21/24. There was no documentation of reviewing Resident 68's fluid intake utilizing Resident 68's Monitor Fluid Intake logs to evaluate and compare to assessed fluid needs. The Wt Mtg indicated, Dietitian met with resident to educate resident on the importance of wt measurements, meeting EEN and hydration needs for wound healing and wt maintenance. Resident verbalized understanding and indicated she is eating more and drinking the protein shakes. No new food preferences at this time. IDT Recommendations: RNA [restorative nursing assistance] dining and continue with weekly weights. RD stated she did not re-assess Resident 68's daily calorie, protein and fluid needs after significant change of condition (further, continued significant wt. loss) even though that was an established standards of performance. The facility's P&P Nutritional Management, dated 1/2025, was not followed and implemented, as the P&P indicated a comprehensive nutrition assessment will be completed by a dietitian upon significant change of condition, and data gathered to assess fluid as required per the facility's P&P.
During an interview on 5/6/25 at 3:10: p.m. with RD, RD stated she did not recommend any additional interventions to increase calories and protein after Resident 68 had lost 16.7% of her body weight over 3 months because we were already giving her fortified diet which adds 500 calories, double protein, HN 4 oz with meals, Prostat and ice cream and she was eating 51-75% of her meals. RD was asked how she determined the interventions were adequate when Resident 68 had 7 lbs further weight loss since her significant wt loss the month prior. RD repeated she was eating 51-75% of her meals. RD was asked if she evaluated whether Resident 68 was in a hypermetabolic (a condition where the body's metabolism is increased above normal levels) and/or hypercatabolic (an abnormally high rate of metabolic breakdown of substances within the body leading to tissue breakdown and weight loss) state using evidence based guidelines for stage 4 pressure injury with co-existing other wounds that could contribute to further increased protein/energy [calories]/fluids per kg of UBW (113 lbs) nutritional needs related to increased demand of nutrients to support wound healing, as evidenced by delayed wound healing of stage 4 pressure injury to coccyx (tailbone), and continued significant weight loss. RD stated she did not need to re-assess daily calorie, protein and fluid needs to find out if Resident 68 was not eating or drinking enough. Lack of sufficient monitoring and evaluation of effectiveness of interventions and lack of comprehensive re-assessment of nutritional needs after a significant change of condition taking into consideration potential changes to metabolic state, and/or discussing with the doctor, may impede identifying a need for alternate nutrition approaches and revision of the nutrition care plan versus continuation of the same nutrition plan of care with negative outcomes.
During review of Resident 68's nutrition assessment, dated 8/27/2024, RD calculated daily calorie needs at 30kcal/kg of admission weight and had not re-evaluated and reassessed Resident 68's daily calorie, protein and fluid needs since admission, despite being admitted with diagnosis of moderate protein calorie malnutrition, multiple occasions of significant unintended weight loss and no improvement in wound healing. Further, RD had not monitored and documented fluid intake from meal trays and compared to assessed needs to bring the quantity of deficit of insufficient fluid intake to the attention of the doctor as required per the facility's P & P titled Nutritional Management, dated 1/2025.
During a review of Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline (CPG), dated 2019, the CPG indicated, Provide 30 to 35 kcalories/kg body weight/day for adults with a pressure injury who are malnourished or at risk of malnutrition. In adults who are underweight or who have had significant unintended weight loss, additional energy intake may be required.
2. During a general dining observation on 5/5/25 from 12:30 p.m. to 12:55 p.m. in the dining room, HN shake was the only ONS observed to be in use for those residents with an order.
During a concurrent observation and interview on 5/05/25 at 1:00 p.m. with CNA 2 in Resident 68's room, Resident 68 was sitting up in bed. CNA 2 was encouraging Resident 68 to eat. Resident 68 stated she received a supplemental shake [HN shake to increase calories and protein) but did not like it so she did not drink it.
During an interview on 05/06/25 at 10:53 a.m. with CNA 1, CNA 1 stated CNAs document quantity consumed of HN (house nourishment shake) with the overall fluid intake from any of the fluids consumed located on the meal tray in which the total number of ml (milliliter) was typed into a box on the Activities for Daily Living (ADL) Flow Sheet (Monitor Fluid Intake/Document Fluid Intake Ml's logs). CNA 1 stated CNAs did not document the type of fluid by name, such as the name HN supplement or shake would not appear on the Document Fluid Intake Ml's flowsheet, therefore there would not be a mechanism for the RD or nursing leadership to provide oversight to ensure the HN supplement (shake or ONS) was being consistently provided as ordered, and would not be able to tell whether the HN ONS was being routinely consumed.
During a concurrent observation and interview on 5/06/25 at 11:50 a.m. with Dietary Supervisor (DS) in the kitchen, 4 ounce (oz) sized cartons of strawberry flavored Mighty Shake were placed on meal trays for those residents who had an order for HN (house nourishment). DS stated we did not have Mightyshakes available yesterday so we made vanilla flavored HN shakes because they are equivalent.
During review of the facility's recipe titled High Protein House Supplement Recipe (HN shake recipe), the HN shake recipe indicated a 4 oz portion provided 117 calories and 6 gm protein per serving.
During a review of Nutrition Facts located on a 4 oz carton of Mightyshakes (MS), the MS provided 220 calories and 6 g of protein per serving, almost doubled the amount of calories provided versus the HN recipe.
During a concurrent interview and record review on 05/06/25 at 3:00 p.m. with RD, Resident 68's Wt Mtg, dated 11/6/24, was reviewed. RD stated Resident 68 weighed 97 lbs on 11/4/24 which was a loss of 10.2% of body weight. RD stated IDT recommendations were to add HN 4 oz w/meals.
During a concurrent interview and record review on 05/06/25 at 3:05 p.m. with RD, Resident 68's Wt Mtg, dated 12/5/24, was reviewed. The Wt Mtg note indicated Resident 68 weighed 90 lbs which was 7.2% further unplanned significant weight loss in a month and was an 18 lb wt loss (16.7% loss of body weight) over 3 months. The Wt Mtg indicated, Dietitian met with resident to educate resident on the importance of wt measurements, meeting EEN [estimated energy needs] and hydration needs for wound healing and wt maintenance. Resident verbalized understanding and indicated she is eating more and drinking the protein shakes.
During an interview on 5/6/25 at 3:20 p.m. with RD, RD was asked how much of the 4 oz HN shake with meals Resident 68 consumed in the past month, after it was initiated a month prior as an intervention to prevent further weight loss. RD stated she would not be able to estimate how many calories and protein she consumed during the past month from the HN shake to determine whether the intervention was adequate to meet Resident 68's nutritional needs because the CNAs document the intake of the HN shake with the overall fluid intake of any beverages on the meal tray that was consumed. RD was asked if it was adequate to follow up on the effectiveness of the HN shake provided to address significant unintended weight loss a month later, during which time Resident 68 had lost 7 more lbs and may have benefited from an alternative ONS option to help minimize further weight loss earlier than waiting a month. RD stated following up a month later was not timely nutrition care.
During a review of Resident 68's Wt Mtg, dated 12/31/24, Wt Mtg indicated, Wt: 85#. Wt Change: -23# (21.3%) x 3 months, po intake: 0-50%, Diet: fortified, double protein diet, Supplements: HN 4 oz with meals, ferrous sulfate, Vit C, Prostat, MVM, Skin: Stage 4 to sacrum, unstageable to R leg, trauma wound to R leg, skin tear to R forearm, Resident sent to acute (12/14) for syncope [fainting] and readmitted (12/16) s/p [status post] IV [intravenous] hydration. Resident with decreased appetite, new wound, and s/p antibiotic tx [therapy] for R [right] leg trauma wound. CDM [Certified Dietary Manager; Dietary Supervisor (DS)] met with resident to update food preferences. Residents likes and dislikes updated, resident desires to take a break from HN and instead add ice cream and chocolate pudding w [with]/L [lunch]&D[dinner]. Resident own RP [responsible party] and aware of increased risks for continued weight loss and skin deterioration with poor meal consumption and in agreement with below recommendations. IDT Recommendations: d/c [discontinue] HN, appetite stimulant, ST [speech therapist] eval. There was no documentation specifying alternative ONS were offered to Resident 68, if any.
During an interview on 05/07/25 at 08:57 a.m. with LVN 3, it was shared with LVN 3 that there was no documentation that Resident 68 was offered an alternative ONS when she did not want HN shake and instead requested ice cream. LVN 3 stated she usually sees the facility using HN shake the majority of the time, and stated, why not Magic Cup instead of ice cream.
During a review of Sysco 4 oz container of ice-cream the facility provided was 130 calories and 2 g protein, versus a 4 oz serving of Magic Cup (Frozen supplement that resembles ice-cream) would provide 290 calories and 9 g protein.
During an interview on 05/07/25 at 09:07 a.m. with Resident 68's specialized MD in wounds, in the presence of LVN 3, MD stated he agreed, without adequate fluid intake and offering alternative nutrition interventions the facility did not do all they could to improve wound healing. (Cross Refer F807)
During an interview on 05/08/25 at 09:16 a.m. with DS, DS stated the facility primarily used HN shake recipe for ONS. DS reviewed the food purchase/ONS purchases from January 2024 to present and stated it was very likely there were no further ONS purchases made by her or the RD, other than one food invoice for one case of 32 oz sized carton of Sysco Imperial Supplement MedPlus Vanilla (which would provide 240 kcal and 10 g pro per 4 oz serving), and Sysco supplemental shake, strawberry and vanilla flavor, which provided 200 kcal and 8 g pro per 4 oz with a delivery date of 5/4/24. DS stated Prostat that was ordered for Resident 68 was purchased and delivered from the facility's central supply and she did not know of any other routine ONS that would be available at the facility. DS stated there was a recall of Sysco health shakes, however, the recall of Sysco Imperial Supplement Shake did not occur until Februrary 2025.
During a review of the U.S. Food and Drug Administration (FDA) website, FDA indicated, On February 22, 2025, [NAME] LLC recalled 4 oz. [NAME] ReadyCare and Sysco Imperial Frozen Supplemental Shakes. Frozen supplemental shakes under brands [NAME] ReadyCare and Sysco were the only shakes that were recalled starting in February 2025. https://www.fda.gov/food/outbreaks-foodborne-illness/outbreak-investigation-listeria-monocytogenes-frozen-supplemental-shakes-february-2025. Statement Regarding Recall of Nutritional Shakes - Prairie Farms Dairy, Inc. The Vital Cuisine Mightyshakes observed in use by the facility on 5/6/25 during lunch trayline were not recalled.
During a review of Resident 68's Progress Notes, (PN) dated 1/16/25, the PN indicated, Met with resident to update food preferences. Resident would like to discontinue with house nourishments and receive ice cream with lunch and dinner instead. Nurse informed. Dietary supervisor available prn., signed by DS.
During a review of Resident 68's PN, dated 1/30/25, the PN indicated, IDT-Skin Integrity Review Mtg: . Asked for ONS [HN shake] to be d/c despite risks vs benefits and high risk of continued weight loss explained.
During review of Resident 68's Discontinue Order, (DO) dated 2/3/25, the DO indicated, House Supplement three times a day 4 oz HN with meals, preferences reviewed with resident and updated by kitchen director [DS].
During a review of Resident 68's admission history and physical examination (H&P), dated 2/5/25 as Late Entry, the H&P indicated, Resident 68 weighed 86 lbs with poor nutrition and continue Ensure [an ONS], however, Resident 68 did not have an order for Ensure, and was not provided with Ensure.
During review of multiple PN's, as indicated above, Resident 68 had been telling the facility since 12/31/24 that she did not like nor want the HN shake (it was recommended by IDT on 11/6/24). There were no documented ONS alternatives specifically listed as to what ONS, if any, were offered to Resident 68 who had documented increased nutritional needs.
During a review of Resident 68's Order Summary Report (OSR), dated 5/8/25, the OSR indicated regular diet, mechanical soft texture, fortified ordered on 1/17/25 and Prostat BID 60ml [increased from 30 ml BID Resident 68 had since admission]. During a review of Resident 68's progress note, dated 2/6/25, she was eating 26-50% of her fortified diet (double protein was no longer documented).
During a review of Resident 68's interdisciplinary nutrition Care Plan Report, with a target date of 5/26/25, Resident 68's nutrition interventions were fortified diet, ice cream with lunch and dinner, Prostat 60 ml BID, antidepressant medication and appetite stimulant medication, vitamins and/or minerals as ordered, ST eval was her nutritional care plan.
During a review of Resident 68's Medication Administration Record (MAR), dated May 2025, the MAR indicated from 5/1/25 through 5/5/25 Resident consumed 50% of the ordered Prostat 8 out of 10 times the Prostat was provided to Resident 68. There was no documentation an alternative nutrition intervention, to promote variety and continued palatability, designed for wound healing was offered to Resident 68 who had been receiving the same Prostat for a prolonged period of time since admission, nine months earlier.
During a review of the facility's P&P titled, Nutritional Management, dated 1/2025, the P&P indicated, Policy: The facility provides care and services to each resident to ensure the resident maintains acceptable parameters of nutritional status in the context of his or her overall condition. Compliance Guidelines: A comprehensive nutritional assessment will be completed by a dietitian within 72 hours of admission, annually, and upon significant change of condition.Components of the assessment may include, but are not limited to:.Food and fluid intake, Evidence of fluid loss.Evaluation/analysis: The dietitian shall use data gathered from the nutritional assessment to estimate the resident's calorie, nutrient, and fluid needs and whether intake is adequate to meet those needs. Current standards of practice/formulas are used in calculating these estimates. Care plan implementation: The resident's goals and preferences regarding nutrition will be reflected in the resident's plan of care. Interventions will be individualized to address the specific needs of the resident.Monitoring/revision:.Evaluating the care plan to determine if current interventions are being implemented and are effective.The care plan will be updated as needed, such as when a resident's condition changes, goals are met or the resident changes his or her goals, interventions are determined to be ineffective, or as new causes of nutrition-related problems are identified. The comprehensive care plan should describe any interventions offered, but declined by the resident or resident's representative.
3. During a review of Resident 68's Wt Mtg, dated 12/31/24, Wt Mtg indicated, Wt: 85#. Wt Change: -23# (21.3%) x 3 months, po intake: 0-50%, Diet: fortified, double protein diet, Supplements: HN 4 oz with meals, ferrous sulfate [form of iron], Vit C, Prostat, MVM [multivitamin with minerals], Skin: Stage 4 to sacrum, unstageable to R leg, trauma wound to R leg, skin tear to R forearm, resident sent to acute [hospital] (12/14/2024) for syncope [fainting] and readmitted (12/16/2024) s/p [status post] IV [intravenous] hydration. Resident with decreased appetite, new wound, and s/p antibiotic tx [therapy] for R leg trauma wound. CDM met with resident to update food preferences. Residents likes and dislikes updated, resident desires to take a break from HN and instead add ice cream and chocolate pudding w[with]/L[lunch]&D[dinner]. Resident own RP [responsible party] and aware of increased risks for continued weight loss and skin deterioration with poor meal consumption and in agreement with below recommendations. IDT Recommendations: d/c [discontinue] HN, appetite stimulant, ST [speech therapy] eval [evaluation].
During a concurrent interview and record review on 05/06/25 at 3:30 p.m. with RD, RD was asked if monitoring fluid intake to assess hydration was part of an RDs responsibility when conducting a nutrition assessment and/or follow up, and RD stated yes. RD was asked if she reviewed Resident 68's fluid intake from meals as documented by CNAs, and RD stated Resident 68 was not on I & O's [No order to require nursing to document all fluid intake and urine output]. RD was asked if a resident's fluid intake from meals was standards of practice to consider when evaluating whether a resident was consuming enough fluids to promote adequate hydration, and RD stated, yes. RD stated she had not been gathering data from resident's individualized Monitor Fluid Intake logs to evaluate fluid intake from meals and had not been documenting fluid intake to compare to a resident's assessed daily fluid needs to assess hydration status which was a component of nutrition assessment.
During a concurrent interview and record review on 05/06/25 at 3:40 p.m. with RD, RD began reviewing Resident 68's Monitor Fluid Intake logs recorded from meals for the week prior to Resident 68's admit to the hospital on [DATE] when IV hydration was administered. RD stated, I don't know how accurate that is [the documentation by CNAs related to ml fluid intake from meal trays] which was why I have not been reviewing the fluid intake logs. RD was asked if she had brought her concern to Quality Assurance committee and participated in providing recommendations for performance improvement related to accurate monitoring, tracking and analyzing hydration status for residents to promote early identification of insufficient fluid intake prior to complications such as dehydration, and RD stated no. RD stated Resident 68 had inadequate fluid intake for the majority of the week based on the fluid monitoring logs from meal trays prior to being discharged to the hospital. RD stated she had not identified the insufficient fluid intake to communicate the concern to IDT and/or the physician as she had not been reviewing the fluid intake logs. RD stated she had not been documenting fluid intake to determine whether Resident 68's daily fluid needs were being met, or improving toward a goal as she had also not re-assessed Resident 68's daily fluid needs after Resident 68 had a significant change of condition. RD did not follow and implement the facility's P & P's titled Nutritional Management, dated 1/2025, Hydration, dated 2022, nor Weight Assessment and Intervention, dated 2011 in which all three P&P's required RD to assess Resident 68's individual fluid needs to establish a goal for fluid intake, including after a significant change of condition, evaluate fluid intake as to whether intake meets Resident 68's individualized hydration needs, and monitor intake and notify the physician responsible for care of Resident 68 if there was lack of improvement toward fluid goals. (Cross Refer F807)
During an interview on 05/06/25 at 03:57 p.m. with Director of Nursing (DON), DON stated the CNAs see how much fluid residents are drinking and they chart that into PCC (software used for resident's electronic health record) so in IDT meetings ADON (Assistant Director of Nursing) should access those monitoring fluid intake logs and discuss with IDT.
During an interview on 05/06/25 at 04:06 p.m. with ADON, ADON stated, yes, daily monitoring of the fluid intake from meals log to identify potential concerns before outcome becomes worse would be ideal, I do not routine[TRUNCATED]

Based on observation, interview, and record review, the facility failed to follow its policy and procedure (P&P) titled, Pain Management, for one of one sampled resident (Resident 77) when Resident 77's pain was not controlled consistently. This failure had the potential for Resident 77's pain not to be correctly managed.
Findings:
During an interview on 5/7/25 at 1:50 p.m. with Resident 77, Resident 77 stated two weeks ago the nurse told her she needed to take a different medication and not her regular pain medication. Resident 77 stated she felt horrible for hours going without her pain medication.
During a review of Resident 77's Physician Order (PO) dated 4/21/25, the PO indicated, Oxycodone HCL [narcotic medication for acute pain 0- no pain, 1-3 mild pain, 4-6 moderate pain interfering with daily activities, 7-9 severe pain, difficult to tolerate or manage, 10 worst pain possible]oral tablet 5 mg [milligram], give 1 tablet by mouth every 4 hours as needed for moderate pain 4-6.
During a review of Resident 77's PO, dated 4/21/25, the PO indicated, Acetaminophen Tablet 325 mg give 2 tablets by mouth every 4 hours as needed for Mild pain 1-3 Not to exceed 3 grams Acetaminophen in 24 hours.
During a concurrent interview and record review on 5/8/25 at 10:25 a.m. with Assistant Director of Nursing (ADON), Resident 77's Medication Administration Record (MAR) dated April 2025 was reviewed. The MAR indicated the following:
On 4/21/25 at 5:00 p.m. Oxycodone HCL 5 mg.
On 4/21/25 at 10:54 p.m. Oxycodone HCL 5 mg.
On 4/22/25 at 10:34 a.m. Oxycodone HCL 5 mg.
On 4/22/25 at 4:16 p.m. Oxycodone HCL 5 mg.
On 4/22/25 at 10:50 p.m. Oxycodone HCL 5 mg.
On 4/23/25 at 6:17 a.m. Oxycodone HCL 5 mg.
On 4/23/25 at 11:38 a.m. Oxycodone HCL 5 mg.
On 4/23/25 at 4:48 p.m. Oxycodone HCL 5 mg.
On 4/23/25 at 11:37 p.m. Oxycodone HCL 5 mg.
On 4/24/25 at 10:00 a.m. Oxycodone HCL 5 mg.
On 4/24/25 at 3: 00 p.m. Oxycodone HCL 5 mg.
On 4/25/25 at 4:54 a.m. Oxycodone HCL 5 mg.
On 4/25/25 at 11:00 a.m. Oxycodone HCL 5 mg.
On 4/26/25 at 6:30 a.m. Oxycodone HCL 5 mg.
On 4/27/25 at 5:13 p.m. Acetaminophen 325 mg.
On 4/28/25 at 3:19 a.m. Acetaminophen 325 mg.
On 4/26/25 at 11:16 a.m. Oxycodone HCL 5 mg.
On 4/29/25 at 11:00 a.m. Oxycodone HCL 5 mg.
On 4/29/25 at 9:30 a.m. Oxycodone HCL 5 mg.
ADON stated Resident 77 was a chronic pain management resident. ADON did not provide an answer for Resident 77 receiving Acetaminophen medication on 4/27/25 and 4/28/25.
During a review of the facility's P&P titled, Pain Management, dated 10/2022, the P&P indicated, Pain Management and Treatment, 1. Based upon the evaluation, the facility in collaboration with the attending physician/prescriber, other health care professional and the resident and/or the resident's representative will develop, implement, monitor and revise as necessary interventions to prevent or manage each individual resident's pain at admission.

Based on observation, interview, and record review, the facility failed to ensure a system to maintain an accurate and complete medical record (electronic health record/EHR) for one of one sampled residents (Resident 57) when the EHR had not contained documentation that an order for 4 ounces (oz) house nourishment (HN shake) with breakfast was provided to Patient 57. In addition, quantity consumed of HN shake was included in the overall fluid intake from all fluids served for breakfast impeding interdisciplinary team (IDT) ability to identify and assess intake of the planned nutrition intervention. Further, due to a Certified Nursing Assistant (CNA) 1 late entry documentation of fluid intake from the breakfast meal, the EHR contained inaccurate information reflecting Resident 57 consumed fluids from her breakfast meal at 11:03 a.m.
This deficient practice had the potential for residents to not receive the ordered nutrition intervention and/or services to support their highest practicable well-being.
Findings:
During a review of Resident 57's Order Summary (OS), dated 6/11/2024, the OS indicated add 4 oz house nourishment with breakfast.
During a review of Posted Meal Times (PMT), located in front of the dining room, the PMT indicated breakfast was served at 7 a.m., lunch at 12 p.m., and dinner at 5 p.m.
During a concurrent observation and interview on 05/06/25 at 11:03 a.m. with CNA 1 in rooms 25-29 hallway, CNA 1 stated she assisted Resident 57 with eating her breakfast earlier in the morning. CNA 1 was observed entering 40 ml (milliliter: a unit used in the metric system for measuring capacity) onto an electronic device attached to the wall in the hallway. CNA 1 stated 40 ml was the total consumption of fluids from all fluids located on Resident 57's breakfast meal tray that consisted of milk, apple juice, and a little tiny bit of HN shake.
During a review of Resident 57's Document Fluid Intake Ml's (DFI) log, dated 5/6/2025, the DFI indicated 11:03 (11:03 a.m.) with 40 documented to the right of 11:03 under a column titled Amount. The other two meal time's listed for 5/6/25 on the DFI indicated 14:44 (2:44 p.m.) and 18:00 (6:00 p.m.). No where on the DFI log nor on the Medication Administration Record was documentation to show the order of 4 oz House Nourishment with breakfast was implemented.
During an interview on 5/6/25 at 3:20 p.m. with RD, RD was asked how much of the 4 oz HN shake with meals Resident 68 consumed in the past month, after it was initiated a month prior as an intervention to prevent further weight loss. RD stated she would not be able to estimate how many calories and protein she consumed during the past month from the HN shake to determine whether the intervention was adequate to meet Resident 68's nutritional needs because CNAs included the HN shake with the overall fluid intake of any beverages consumed with the meal.
During an interview on 05/07/25 at 09:51 a.m. with Director of Staff Development (DSD), DSD stated he was responsible for training CNAs on how to document resident consumption of solid food intake and of fluids from meals provided. DSD showed his power point training on how he instructed CNAs to document quantity of total ml of fluids consumed from a meal tray to include oral nutrition supplements (ONS) such as HN shake on the ADL (Activities of Daily Living) flow sheet (ie.DFI log). DSD stated the facility's policy and procedure (P&P) did not provide specific details on how and where to document ONS but that was how he trained CNAs to do it. DSD stated the closest P&P to this subject matter was titled Serving a Meal.
During a review of the facility's P&P titled, Serving a Meal, dated 1/2025, the P&P indicated, Remove the tray when the resident has finished and record the percentage of food consumed as 25%, 50%, 75% or 100%.
During a review of the facility's P&P titled, Nutritional Management, dated 1/2025, the P&P indicated, Policy: The facility provides care and services to each resident to ensure the resident maintains acceptable parameters of nutritional status.Compliance Guidelines: A comprehensive nutritional assessment will be completed by a dietitian.Components of the assessment may include, but are not limited to:.Food and fluid intake, Monitoring/revision:.Examples of monitoring include: Evaluating the care plan to determine if current interventions are being implemented and are effective.
During a review of the facility's P&P titled, Documentation in Medical Record, dated 2022, the P&P indicated, Policy: Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy. Documentation shall be accurate, relevant, and complete, containing sufficient details about the resident's care and/or response to care.

Based on observation, interview, and record review, the facility failed to ensure staff followed infection control practices for one of one sampled residents (Resident 34) during the administration of an injectable medication. This failure had the potential to increase the risk of exposure to blood-borne pathogens.
Findings:
During a concurrent observation and interview in Resident 34's room on 5/6/25 at 11:09 a.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 was administering Humalog insulin quick pen (used to treat low blood sugar) to Resident 34 in the left lower abdomen. LVN 2 used her ungloved hand, to uncap and dispose of the contaminated needle tip. LVN 2 stated, I'm not going to lie, I just grabbed it without thinking and threw it out.
During a review of the facility's policy and procedure (P&P) titled, Medication Administration -Subcutaneous Insulin, dated 1/2023, the P&P indicated, Put on gloves, engage safety device, and discard syringe and needle in appropriate syringe disposal container.

Based on observation, interview, and record review, the facility failed to ensure accurate documentation and accountability for the destruction of controlled substances, the facility did not ensure controlled substances were destroyed in the presence of a licensed pharmacist, and destruction was appropriately documented with a nurse and a pharmacist signatures. This failure had the potential to result in diversion or mismanagement of controlled medications.
Findings:
During an observation on 5/7/25 at 8:38 a.m. in the Director of Nursing (DON) office, there was a locked cabinet used to store medications to be destroyed.
During a concurrent interview and record review on 5/7/25 at 8:38 a.m. with the Assistant Director of Nursing (ADON), The facility Controlled Medication Destruction Log (MDL), dated 03/25 and 04/25 were reviewed. The MDL indicated, entries had not been dated and signed without a pharmacist involvement. ADON stated she was unable to clarify the following entries: had been dated and signed without pharmacist involvement. The MDL indicated the following:
On 3/6/25 RX # R817831 Oxycodone [Oxycodone is a prescription opioid pain medication used to relieve moderate to severe pain (generally falls within a range of 5-10 on a 0-10 pain scale)]. 10 mg.
On 3/7/25 RX # 752758 Lorazepam [providing short-term relief from anxiety symptoms and is often prescribed for various anxiety disorders, including generalized anxiety disorder and panic disorder]. 0.5 mg.
On 3/7/25 RX # 752006 Morphine 15 mg. [pain medication used to relieve severe pain (generally falls within a range of 7-10 on a 0-10 pain scale)].
On 3/7/25 RX # 831375 Hydrocodone [a semi-synthetic opioid that is used to treat moderate to severe pain and as a cough suppressant (generally falls within a range of 5-6 on a 0-10 pain scale)]. 5-325 mg.
On 3/7/25 RX # C8809092 Lorazepam 0.5 mg.
On 3/7/25 RX # C0874708 Lorazepam 30 ml.
On 3/7/25 RX # 824460 Morphine 15 mg.
On 5/5/25 RX # 831375 Hydrocodone 10-325 mg.
During an interview on 5/7/25 at 9:08 a.m. with Pharmacy Consultant (PC), PC stated she had not participated in the destruction of the medications in question. PC stated the nurse had incorrectly documented the destruction of narcotics without proper verification. PC stated no concurrent destruction had occurred for those entries and the documentation errors did not reflect actual disposal events.
During a review of the facility's policy and procedure (P&P) titled, Discarding and Destroying Medications, dated 4/2019, the P&P indicated, Policy Statement: Medications will be disposed of in accordance with federal, state and local regulations governing management of non-hazardous pharmaceuticals, hazardous waste and controlled substances .3b. the receiving pharmacist and a registered nurse employed by the facility sign a separate log that lists the resident's name; the name, strength, prescription number (if applicable) and amount of the medication returned; and the date the medication was returned .6c. Disposal of controlled subtances must take place immediately (no longer than three days) after discontinue of use by the resident .7d. Document the disposal on the medication disposition record. 7e. Include the signature(s) of at least two witnesses .11. The medication disposition record will contain the following information: a. The resident's name; b. Date medication disposed; c. the name and strength of the medication; d. The name of the dispensing pharmacy; e. the quantity disposed; f. Method of disposition; g. Reason for disposition; and h. Signature of witnesses.

Based on observation, interview, and record review, the facility failed to ensure three of twenty eight opportunities for medication administration were performed without error, resulting in an 11% medication error rate. These failures had the potential for:
1. Resident 46, ineffective medication delivery.
2. Resident 46, omissions are inconsistent with manufacturer instructions for use.
3. Resident 34, to rotate injection sites as required.
Findings:
1. During a review of the manufacturer's instructions for Combivent Respimat(inhaler for breathing difficulties) indicated, The patient should exhale fully, place lips around the mouthpiece, then inhale slowly and deeply while pressing the inhaler button. After inhalation, the patient should hold their breath for 10 seconds or as long as comfortable.
During an observation on 5/6/25 at 9 a.m. in Resident 46's room during a medication pass, a Respiratory Therapist (RT) was observed administering Combivent Respimat to Resident 46. Resident 46 was not instructed to exhale fully prior to inhalation and hold their breath following the dose.
During an interview on 5/6/25 at 9:15 a.m. with RT, RT stated, I just forgot to tell him to exhale and hold his breath. I know I'm supposed to, but I was moving quickly.
2. During a review of the manufacturer's instructions for Ellipta (inhaler for breathing difficulties) indicated: Instruct the patient to exhale fully before inhaling the dose. After inhaling, the patient should hold their breath for about 3-4 seconds, or as long as comfortably possible.
During a cocurrent observation and interview on 5/6/25 at 9 a.m. in Resident 46's room, the RT was administering Ellipta to Resident 46. Resident 46 was not instructed to exhale prior to inhalation and was not told to hold their breath after receiving the dose. At 9:15 a.m., the RT stated, I just forgot to do it-I'll make sure to go slower next time.
3. During a review of the manufacturer's instructions for Humalog (used to treat low blood sugars) indicated, Injection sites should be rotated within the same region to reduce the risk of lipodystrophy [how the body breaks down fat].
During a concurrent observation and interview on 5/6/25 at 9:10 a.m. in Resident 34's room, Licensed Vocation Nurse (LVN) 2 was administering Humalog insulin to Resident 34 in the left lower abdomen. At 9:20 a.m., with LVN 2 stated, I gave it in the same spot as before because I forgot to rotate. I'll try to do better next time.
During a review of Resident 34's Medication Administration Record, (MAR) dated 5/1/25, the MAR indicated, the left lower abdomen was also the last documented injection site.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review the facility failed to:
1. Follow the planned menu for finger foods diet for one of one sample resident (Resident 18) during lunch trayline (a system of food preparation).
2. Ensure the allotted fluid from dietary was followed as ordered pertaining to a fluid restriction for one of one sample resident (Resident 32).
These failures had the potential for Resident 18 to have loss of independence and dignity, and Resident 32 to not have adequate hydration.
Findings:
1. During an observation on 5/6/25 at 12:03 p.m. in the kitchen during lunch trayline observation, Resident 18's meal tray card indicated finger foods. A whole piece of chocolate cake was served onto Resident 18's lunch meal tray and placed on the meal delivery cart for distribution. Per the therapeutic diet spreadsheet Chocolate cake cut into smaller pieces was the planned menu for finger foods.
During an interview on 05/06/25 at 12:03 p.m. with Registered Dietitian (RD), RD was asked to check if the planned menu for finger foods was followed. RD stated the cake was not cut into pieces as written on the therapeutic menu extension, it was just a smaller piece.
During an observation on 5/6/25 at 12:09 p.m. in the kitchen, observed RD giving the chocolate cake to staff and asked them to cut into smaller pieces as indicated on Resident 18's meal tray ticket and on the menu. RD stated she did not like that because it might fall into pieces when picked up.
During a review of Resident 18's Diet Order (DO), dated 5/1/23, the DO indicated, Regular diet: regular texture, thin liquids consistency, finger foods.
During a review of Resident 18's Meal Tray Ticket (MTT), the MTT indicated, Resident 18 was on a finger food diet.
During a review of Resident 18's Care plan-nutrition status (CP), dated 7/27/23, the CP indicated, Resident 18 is at risk for weight loss, dehydration, skin breakdown, and altered nutritional status.interventions: Diet as orders: finger food, fortified, regular diet.
During an interview on 5/6/25 at 12:13 p.m. with RD in the kitchen, RD stated she approved the menus, including the planned menu for finger foods. RD stated she was aware it was the facility's RD responsibility to review and approve the menus and she had not identified concerns with the finger foods menu in advance in order to provide instruction to dietary staff on modification to the menu to address concerns that it may impede a resident's dignity while eating amongst others, or potential with difficulty getting the food into the mouth, if the food might be falling between the fingers.
During an interview on 05/08/25 at 10:18 a.m. with the Dietary Supervisor (DS), DS stated the RD did sign the current menu cycle that included cutting up the cake into smaller pieces for the finger foods planned menu. DS stated she expects the dietary aid (DA) who prepared and placed the whole cake onto Resident 18's lunch meal tray to have had the skill set to follow the planned menu as indicated on the therapeutic spreadsheet for finger foods.
During a review of the facility's job description (JD) titled Dietitian, dated 2023, the JD indicated, Major Duties and Responsibilities: Reviews menu changes to ensure compliance with the facility's policy and procedures and state and federal guidelines. Updates diet orders and menu changes as required. Conducts audits of relevant nutritional care on a routine basis.
During a review of the facility's policy and procedure (P&P) titled Menus and Adequate Nutrition, dated 2/2025, the P&P indicated, The facility's dietician or other clinically qualified nutrition professionals will review all menus for nutritional adequacy and approve the menus.
During a review of the facility's diet manual (DM), dated 2023, the DM indicated, Regular Diet-Finger Foods (RDFF), dated 2023, the RDFF indicated the finger foods diet is a regular diet that provides food in appropriate size and shape to be eaten without utensils, but rather with fingers. This allows residents to maintain independence, dignity and quality of life.cut food to size per the diet order. If no size is indicated, cut food in bite-size pieces (approximately 1).
During a review of the facility's P&P titled Tray Identification, dated 4/2007, the P&P indicated, Appropriate identification/coding shall be used to identify various diets. 1. To assist in setting up and serving the correct food trays/diets to residents, the food services department will use appropriate identification to identify the various diets. 2. The food service manager or supervisor will check trays for correct diets before the food carts are transported to their designated areas.
During review of the Academy of Nutrition and Dietetics (AND) Nutrition Care Manual (NCM), dated 2025, the NCM defined finger foods as finger foods can be easily picked up with the hands without falling apart.Indication: Using fingers to pick up foods enables self-feeding, independence, and diet adequacy.
2. During a review of Resident 32's facesheet, the facesheet indicated Resident 32 was admitted on [DATE] with diagnosis of end stage renal disease.
During a review of Resident 32's Minimum Data Set (MDS-a federally mandated resident assessment tool) dated 5/5/25, the MDS section C indicated Resident 32's Brief Interview for Mental Status (BIMS-an assessment tool used by facilities to screen an identify memory, orientation, and judgement status of the resident) was a score of 15 (able to understand and verbalize thoughts and needs).
During a review of Resident 32's DO, dated 11/14/24, the DO indicated Resident 32 was on a fluid restriction.
During a review of Resident 32's CP dated 8/29/23, the CP indicated Resident 32 is at risk for weight loss, dehydration, skin breakdown, and altered nutritional status r/t [related to] medical condition/dx [diagnosis] ESRD [end stage renal [kidney] disease] w/[with] dialysis tx [treatment]. Interventions: diet as ordered.Fluid restriction: 1500 ml [milliliters-a measurement of volume]/ [per] day; Dietary: 1080 ml; Nursing: 420 ml.
During a review of Academy of Nutrition and Dietetics Nutrition Care Manual (NCM), dated 2025, the NCM indicated to determine how to distribute total fluids throughout the day.
During a concurrent interview and record review on 05/08/25 at 10:13 a.m. with DS, Resident 32's meal tray card (MTC) indicated 1080 ml fluid restriction. DS reviewed Resident 32's MTC that listed the following: 4 fl oz [fluid ounces- a measurement of liquid] fruit juice and 8 fl oz Soy Milk. For lunch 8 fl oz Soy Milk and 4 fl oz Water. For dinner 4 fl oz of Soy Milk and 4 fl oz Water. DS stated, 4 oz is missing and she [Resident 32] has been stating she is thirsty too. DS stated the facility's expectation was for the total allotted amount of 1080 fl oz per 24 hours to be served by dietary, not more and not less.
During a review of the facility's policy and procedure (P&P) titled, Therapeutic Diet Orders, the P&P indicated The facility provides all residents with foods in the appropriate form and/or the appropriate nutritive content as prescribed by a physician, and/or assessed by the interdisciplinary team to support the resident's treatment/plan of care, in accordance with his/her goals and preferences.

Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident(Resident 68) beverage and/or liquid preferences were obtained to provide sufficient drinks and liquids the resident prefers to help maintain hydration. Facility's failure to obtain Resident 68's beverage preferences placed Resident 68 at an increased risk for dehydration and delayed wound healing.
Findings:
During a concurrent observation and interview on 5/7/25 at 11:58 a.m. with Resident 68 in Resident 68's room, Resident 68 stated when she was at home she liked to drink Pepsi, Kool-Aid, and pineapple juice. Resident 68 stated in here they only give her the liquids they have in the kitchen that day. Resident 68 stated no one has come to ask her preferences for liquids.
During a review of Resident 68's RD [Registered Dietitian]/IDT [interdisciplinary team] Weight [wt] Variance Meeting [mtg] (Wt Mtg), dated 12/31/24, the Wt Mtg indicated, Wt: 85# (pounds). Wt Change: -23# (21.3%[percent]) x [for] 3 months, po [by mouth] intake: 0-50% [of total meals], Diet: fortified [increased calories], double protein diet, Supplements: HN [house nourishment/HN shake] 4 oz [ounce] with meals, ferrous sulfate [a compound containing iron], Vit [vitamin] C, Prostat [supplement to increase protein and calories], MVM [multivitamin with minerals], Skin: Stage 4 [pressure injury with full-thickness skin and tissue loss] to sacrum [bone in the lower portion of the spine], unstageable [pressure injury with obscured full-thickness skin and tissue loss] to R [right] leg, trauma wound to R leg, skin tear to R forearm, Resident sent to acute [hospital] (12/14/2024) for syncope [fainting] and readmitted [to skilled nursing facility on 12/16/2024] s/p [status post] IV [intravenous] hydration. Resident with decreased appetite, new wound, and s/p antibiotic tx [therapy] for R leg trauma wound. CDM [Certified Dietary Manager/DS-Dietary Supervisor] met with resident to update food preferences. Residents likes and dislikes updated, resident desires to take a break from HN [house nourishment shake to increase calories and protein] and instead add ice cream and chocolate pudding [Note: both items turn to liquid at room temperature and therefore are considered alternative sources of liquids] w[with]/L [lunch] & D [dinner],
During a concurrent interview and record review on 05/08/25 at 10:11 a.m. with DS, DS stated she obtained Resident 68's food preferences frequently. DS was asked if she obtained Resident 68's beverage and/or liquid preferences. DS stated, yes, she offers the beverages they have such as milk (soy or almond and regular), punch, iced tea, water, fruit juice (100%-pineapple, orange, grape, apple, and cranberry juice) as these juices are always in stock. DS stated these preferences are documented on Resident 68's meal tray card. DS reviewed Resident 68's meal tray card that indicated for breakfast 4 fl [fluid] oz Fruit Juice [flavor unspecified], 8 fl oz Milk Whole, for lunch 4 oz ice cream, 4 fl oz Milk Whole, 8 fl oz SF [sugar free] Beverage [flavor unspecified] and for dinner 4 oz ice cream, 8 fl oz Iced Tea, and 4 fl oz Milk Whole. DS stated the liquids listed on Resident 68's meal tray card were standing orders, meaning they consisted of the routine beverages facility maintained in stock. It was shared with DS that Resident 68 stated she had to drink what was given to her on the meal trays but if she were home one of her beverages she liked to drink was pineapple juice. DS showed a carton of pineapple juice that was readily available in the kitchen. DS stated if she knew she liked pineapple juice she would have offered it. DS was asked if there were any other facility policies and procedures (P&P) that guided staff to obtain beverage preferences as the P&P titled Food Preferences, dated 2023, indicated, Food preferences will be obtained as soon as possible.Updating of food preferences will be done as the resident's needs change and/or during the quarterly review, and lacked specific guidance directing staff to obtain liquids preferences. DS stated that was the only P&P the facility had related to preferences whether food or beverage.
During a review of Resident 68's Nutrition Status Care Plan Report (IDT nutrition care plan/IDTNCP), dated 5/6/2025, the IDTNCP indicated, Goal: Will not exhibit s/s [signs/symptoms] of dehydration, there were no beverage preferences listed and/or resident's goals related to person centered care to direct acceptable interventions in accordance with Resident 68's preferences on how to achieve the goal of preventing dehydration.
During a review of the facility's P&P titled, Hydration, dated 2022, the P&P indicated, Policy: The facility offers each resident sufficient fluid, including water and other liquids, consistent with resident needs and preferences to maintain proper hydration and health. Compliance Guidelines: The facility will utilize a systematic approach to optimize the resident's hydration status: Developing and consistently implementing pertinent approaches. Identification/assessment: The dietary manager or designee shall obtain the resident's beverage preferences upon admission, significant change in condition, and periodically throughout his or her stay.Care plan implementation: The resident's goals and preferences regarding hydration will be reflected in the resident's plan of care. Interventions will be individualized to address the specific needs of the resident.

Based on observation, interview, and record review the facility failed to ensure sanitary conditions in the kitchen when:
1. A brown colored substance and a dead bug were observed between a reach-in freezer and reach-in refrigerator.
2. The ice machine was not sanitized in accordance with manufacturers' guidelines.
3. Baseboards were observed to be peeling away from the wall under a sink leaving a potential entry for pests.
These failures placed the residents at an increased risk for foodborne illness.
Findings:
1. During a concurrent observation and interview on 05/05/25 at 10:04 a.m. with Dietary Supervisor (DS) in the kitchen, a brown colored substance on the floor behind a white pest control trap located between a reach-in refrigerator and a reach-in freezer was observed. DS was asked what the brown colored debris/substance was, and DS stated, I don't know. DS stated the floor between the freezer and refrigerator was dirty with debris and the external side stainless steel walls of both units that faced each other had a buildup of dust.
During an interview on 05/05/25 at 10:04 a.m. with DS, DS stated she had not seen any pests in the kitchen.
During a concurrent observation and interview on 05/05/25 at 10:29 a.m. with Maintenance Supervisor (MS) in the kitchen, MS observed the round brown colored item on the floor behind a white pest control trap located between a reach-in refrigerator and a reach-in freezer. MS stated that was a bug, and it looked like a water bug which he stated was a type of cockroach. MS stated the floor between the two units was dirty with debris and a dead waterbug/cockroach, as well as a buildup of dust alongside the external surfaces of the two units that faced each other. MS observed behind the two units in which there was another white pest control trap and dirty flooring. MS stated the white pest control traps were placed there by outside pest control company.
During a review of the FDA Food Code (FDAFC), dated 2022, FDAFC indicated, Non-food contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues.
During a review of FDAFCA, dated 2022, FDAFCA indicated, The objective of cleaning focuses on the need to remove organic matter from food-contact surfaces so that sanitization can occur and to remove soil from nonfood contact surfaces so that pathogenic [capable of causing disease] microorganisms will not be allowed to accumulate, and insects and rodents will not be attracted.
2. During an interview on 05/05/25 at 10:13 a.m. with MS, MS stated he was responsible for cleaning the ice machine. MS stated the facility did not have an outside vendor to clean the ice machine. MS stated once a month he deep cleaned the ice machine located in the kitchen, which was the facility's only ice machine. MS stated the only product that was circulated through the ice machine was Nickel Safe Ice Machine Cleaner (NSIMC) and he showed the bottle of NSIMC. MS was asked how he sanitized the ice-machine and MS stated with Nickel Safe Ice Machine Cleaner, it does both.
During a review of the manufacturer's guidelines (MGs) for the Koolaire Ice Machine located in the kitchen, the MGs indicated, Cleaning/Sanitizing Procedure: This procedure must be performed at a minimum of once every six months.Ice machine cleaner is used to remove lime scale and mineral deposits. Ice machine sanitizer disinfects and removes algae and slime.Wait until the trough refills, then add the proper amount of Manitowoc Ice Machine Sanitizer to the water trough.
During a review of the facility's policy & procedure (P&P) titled Ice Machine Cleaning Procedures (IMCP), dated 2023, the IMCP indicated, The ice machine needs to be cleaned and sanitized monthly. Information about the operation, cleaning and care of the ice machine can be obtained from owner's manual, the manufacturer and/or in the directional panel on the inside of the machine. 3. Clean inside of ice machine with a sanitizing agent per the manufacturer's instructions.
3. During a concurrent observation and interview on 05/05/25 at 10:08 a.m. with DS in the kitchen, the baseboards underneath the sink were separating from the floor showing an open crevice. DS stated the open crevice between the floor and baseboard was identified via audit of the kitchen by the Registered Dietitian and MS was aware. DS did not know when the repair was to be made.
During a concurrent observation and interview on 05/05/25 at 10:32 a.m. with MS in the kitchen, MS observed the baseboard separating from the floor alongside the wall in which the dirty side of the dish machine was located. MS stated that it could be an entry for pests and stated he was aware. MS stated the facility started talking about the need to fix that and had been talking about replacing the flooring. MS was asked if there were any action plans put into place that he could provide for review, and MS stated no.
During a review of Food & Nutrition-Monthly Inspection Checklist (FNMIC), dated 03/25/25, the FNMIC indicated old tile needs repair and also baseboards.
During a review of FNMIC, dated 04/15/25, the FNMIC indicated old tile, baseboards repair.
During a review of the facility's P&P titled Sanitation Inspection, the P&P indicated it is the policy of this facility as part of the department's sanitation program, to conduct inspections to ensure food service areas are clean, sanitary and in compliance with applicable state and federal regulations.
According to the FDA (Food and Drug Administration) Food Code 2013, Floors that are of smooth, durable construction and that are nonabsorbent are more easily cleaned. Requirements and restrictions regarding floor coverings, utility lines, and floor/wall junctures are intended to ensure that regular and effective cleaning is possible and that insect and rodent harborage is minimized. (Cleanability 6-201.11 Floors, Walls, and Ceilings. 6-201.12 Floors, Walls, and Ceilings, Utility Lines)

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was administered antipsychotic (Seroquel-use to treat delusional thoughts) medication as ordered by the physician. This failure resulted in Resident 1 not receiving his medication and the potential for adverse side effects.
Findings:
During a review of Resident 1's Medication Administration Record (MAR) dated 3/25, the MAR indicated, Seroquel XR Oral Tablet Extended Release 24 Hour 50 mg (milligram). Give 1.5 tablet by mouth at bedtime. There was a 9 (indicating other/see nurse notes) documented on the MAR for 3/20, 3/22, 3/23, 3/24, 3/29, and 3/30.
During a review of Resident 1's Physicians Order (PO) dated 3/25, the PO indicated Seroquel XR Oral Tablet Extended Release 24 Hour 50 mg. Give 1.5 tablet by mouth at bedtime.
During a review of Resident 1's Progress Notes (PN) dated 3/20/25, the PN indicated, Seroquel XR Oral Tablet Extended Release 24 Hour 50 mg. Not available, pending delivery.
During a review of Resident 1's PN dated 3/22/25, the PN indicated, Seroquel XR Oral Tablet Extended Release 24 Hour 50 mg. Not available, pending delivery.
During a review of Resident 1's PN dated 3/23/25, the PN indicated, Seroquel XR Oral Tablet Extended Release 24 Hour 50 mg. Not available, pending delivery.
During a review of Resident 1's PN dated 3/24/25, the PN indicated, Seroquel XR Oral Tablet Extended Release 24 Hour 50 mg. Not available, pending delivery.
During a review of Resident 1's PN dated 3/29/25, the PN indicated, Seroquel XR Oral Tablet Extended Release 24 Hour 50 mg. Not available, pending delivery.
During a review of Resident 1's PN dated 3/30/25, the PN indicated, Seroquel XR Oral Tablet Extended Release 24 Hour 50 mg. Not available, pending delivery.
During a concurrent interview on 4/10/25 at 1:33 p.m. with Director of Nursing (DON), DON reviewed Resident 1's 3/25 EMAR. DON confirmed Resident 1 was not given his ordered Seroquel medication on 3/20, 3/22, 3/23, 3/24, 3/29, and 3/30. DON stated all staff (nurses) were recently in-serviced on notifying pharmacy and the physician when medication was not available. DON stated Resident 1 should have been given the ordered Seroquel medication.
During an interview on 4/10/25 at 2:03 p.m. with Licensed Vocational Nurse (LVN), LVN stated he does not remember the exact date but does recall Resident 1 running out of his ordered Seroquel. LVN stated, I didn't give him (Resident 1) his medication because it (Seroquel) wasn't in the med (medication) cart. LVN stated he did not notify pharmacy and Resident 1 ' s physician the medication was not available.
During a review of the facility's policy and procedure (P&P) titled, Medication Orders dated 1/23, the P&P indicated, The prescriber shall be contacted by nursing for direction when delivery of a medication will be delayed or the medication is not available.

Based on observation, interview, and record review, the facility failed to follow it's own procedure and procedure (P&P) when two of two sampled Certified Nursing Assistant (CNA 1 and CNA 2) were not wearing their required company-issued identification badge while on duty. This failure had the potential for residents and family members to not be able to identify the staff members.
Findings:
During a concurrent observation and interview on 3/26/25 at 11:31 a.m. with CNA 1, CNA 1 was not wearing an identification badge. CNA 1 stated she had forgotten her identification badge.
During a concurrent observation and interview on 3/26/25 at 11:32 a.m. with CNA 2, CNA 2 was not wearing an identification badge, CNA 2 stated she had left her identification badge in her car.
During an interview on 3/26/25 at 12:1 p.m. with Director of Staff Development (DSD), DSD stated it was the facility practice for all staff to wear identification badge when on duty.
During a review of the facility P&P titled, Identification Badges, dated 2024, the P&P indicated, 1. All employees are required to wear an identification badge during their hours worked.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was administered medication as ordered by the physician. This failure resulted in Resident 1 not receiving her medication and the potential for adverse side effects.
Findings:
During a review of Resident 1's Order Recap Report (ORR-physician order) dated 2/1/25-2/28/25, the ORR indicated, Rosuvastatin Calcium Tablet 20 mg (milligrams-unit of measurement) give 1 tablet by mouth at bedtime for hyperlipidemia (elevated fat in the blood) .start date 11/16/24.
During a review of Resident 1's Medication Administration Record (MAR) dated 2/25, the MAR indicated, Rosuvastatin Calcium 20 mg give 1 tablet by mouth at bedtime. There was a 9 (indicating other/see nurse notes) documented on the MAR for 2/2, 2/6, 2/11-2/13, 2/19-2/21 and 2/27-2/28.
During a review of Resident 1's Progress Notes (PN) dated 2/2/25, the PN indicated, Emar -Administration Note.Rosuvastatin Calcium.pending delivery.
During a review of Resident 1's PN dated 2/6/25, the PN indicated, Emar -Administration Note.Rosuvastatin Calcium.not available, pending delivery.
During a review of Resident 1's (PN dated 2/11/25, the PN indicated, Emar -Administration Note.Rosuvastatin Calcium.on order.
During a review of Resident 1's PN dated 2/12/25, the PN indicated, Emar -Administration Note.Rosuvastatin Calcium.pending delivery.
During a review of Resident 1's PN dated 2/13/25, the PN indicated, Emar -Administration Note.Rosuvastatin Calcium.Not available, pending delivery.
During a review of Resident 1's PN dated 2/19/25, the PN indicated, Emar -Administration Note.Rosuvastatin Calcium.pending delivery.
During a review of Resident 1's PN dated 2/20/25 and 2/21/25, the PN indicated, Emar -Administration Note.Rosuvastatin Calcium.Not available, pending delivery.
During a review of Resident 1's PN dated 2/27/25 and 2/28/25, the PN indicated, Emar -Administration Note.Rosuvastatin Calcium.Pending delivery.
During an interview on 3/6/25 at 4:18 p.m. with Director of Nursing (DON), DON stated when the medications were not available for administration, the nurse should have called the pharmacy to see when the medication was going to be delivered, and the physician should have been notified.
During a review of the facility's policy and procedure (P&P) titled, Medication Orders dated 1/23, the P&P indicated, The prescriber shall be contacted by nursing for direction when delivery of a medication will be delayed or the medication is not available.

Based on interview and record review, the facility failed to maintain confidentiality of medical records for one of three sampled residents (Resident 1) when a screen shot (a digital image that captures the exact content displayed on a computer or mobile device screen at a specific moment) of Resident 1's medical record was taken and shared by a text message. This failure resulted in Resident 1's personal health information to be viewed by others who was not be involved in Resident 1's care.
Findings:
During a review of a complaint received from an anonymous complainant, a screen shot was included. The screen shot contained Resident's 1 picture and medical information which included Resident 1's birthdate, age, allergies, code status, and gender. Anonymous complainant indicated the screen shot of Resident 1's medical records was taken and shared by a staff member working at the facility.
During a concurrent interview and record review on 1/16/25 at 1 p.m. with Administrator and Director of Nurses (DON), Administrator and DON reviewed the screen shot and confirmed the screen shot contained Resident 1's picture, and medical information including birthdate, age, allergies, age, code status, and gender. DON stated the screen shot was taken from the kiosk (touchscreen computer) used by Certified Nursing Assistant (CNA) to chart on residents Activities of Daily Living (ADL). Administrator and DON both stated taking screen shot of the kiosk with resident information was not allowed.
During an interview on 1/16/25 at 1:56 p.m. with CNA, CNA stated taking screen shot of the kiosk was against HIPAA (Health Insurance Portability and Accountability Act). CNA stated the kiosk contained resident personal information including resident picture, allergies, birthdate, and some other things.
During an interview on 1/16/25 at 2:30 p.m. with Administrator in Training (AIT), AIT reviewed the screen shot and confirmed the screen shot contained Resident 1's picture, and medical information including birthdate, age, allergies, age, code status, and gender. AIT stated taking screen shot of the kiosk with resident information was not allowed.
During a review of the facility's policy and procedure (P&P) titled, Confidentiality and Non-Disclosure Agreement, date 2014, the P&P indicated, 2. Only authorized users are granted access to resident and facility information.
During a review of the facility's P&P titled, Protected Health Information (PHI), Safeguarding Electronic, dated 2014, the P&P indicated, Electronic protected health information (e-PHI) is safeguard by administrative, technical and physical means to prevent unauthorized access to protected health information.

Based on interview and record review, the facility failed to implement its policy and procedure (P&P) when an outbreak was not reported to California Department of Public Health (CDPH-state health department) when two of twelve sampled residents (Resident 3 and Resident 4) were diagnosed with scabies (a contagious skin disease marked by itching and small raised red spots, caused by the itch mite). This failure resulted in the CDPH being unaware of the outbreak.
Findings:
During a review of Resident 3' s Wound Physician Consultation Note (completed by Physician 1) (WPCN), dated 12/9/24, the WPCN indicated, The patient with rash on chest.Treatment.Better now, continue scabies treatment.
During a review of Resident 4' s Wound Physician Consultation Note (completed by Physician 1) (WPCN), dated 12/9/24, the WPCN indicated, The patient with rash on back/chest/arm.Treatment.continue scabies treatment.
During an interview on 12/11/24 at 11:22 a.m. with LVN/IP 1, LVN/IP 1 stated on 12/4 Resident 4 and Resident 3 were the first residents presented with a rash and were treated for scabies.
During an interview on 12/11/24 at 12:06 p.m. with LVN/IP 1, LVN/IP 1 stated the scabies outbreak was reported to the county health department but was not reported to CDPH because there was no confirmed skin scraping (specimen of a suspected lesion which is sent to a laboratory for identification).
During an interview on 12/13/24 at 10:30 a.m. with Director of Nursing (DON), DON stated the scabies outbreak was not reported because there was no confirmation.
During an interview on 1/8/25 at 10:49 a.m. with Administrator, Administrator stated a scabies outbreak should have been reported to CDPH when there were two or more cases even if the cases were not confirmed. Administrator stated when the scabies outbreak was reported to the county health department it should have been reported to CDPH.
During a review of the California Department of Public Health Prevention and Control of Scabies in California Healthcare Setting dated 8/2020, the guidance indicated, An outbreak should be assumed to be occurring following diagnosis of a single case, until screening of all new patients and staff for scabies has been completed without identifying additional suspect cases. An outbreak cannot be conclusively excluded for at least 6 weeks following the last unprotected exposure to the case.
During a review of the facility ' s P&P titled, Reporting Communicable Diseases revised 7/14, the P&P indicated, The Infection Preventionist is responsible for notifying the local, district, or state health department of confirmed cases of state-specific reportable diseases.

Based on interview and record review, the facility failed to ensure one of twelve sampled residents (Resident 8) was referred to the dermatologist as ordered by the physician. This failure had the potential to result in a delay of treatment.
Findings:
During a review of Resident 8's Progress Note (PN), dated 11/26/24 at 1:54 p.m., the PN indicated, (Doctor name) in to see resident on 11/25/24.Dermatology consult ordered.
During a review of Resident 8's Order Details (OD), dated 11/26/24, the OD indicated, May see dermatologist for generalized rash.
During a concurrent interview and record review on 12/11/24 at 12:06 p.m. (16 days after the order was received) with Licensed Vocational Nurse/Infection Preventionist (LVN/IP) 1, LVN/IP 1 reviewed Resident 8's clinical record. LVN/IP 1 was unable to provide documentation Resident 8 was referred to the dermatologist. LVN/IP 1 stated the referral process had not been started.
During an interview on 1/10/25 at 9:45 a.m. with Social Service Director (SSD), SSD stated when a referral was ordered by the physician the nurses were to place it in the social service binder so the appointment could be scheduled. SSD stated a referral should be followed up on within a week.
During a review of the facility's policy and procedure (P&P) titled, Referrals, Social Services dated 12/08, the P&P indicated, Social Services will collaborate with the nursing staff or other pertinent disciplines to arrange for services that have been ordered by the physician.

Based on interview and record review, the facility failed to ensure physician orders were implemented for one of two sampled residents (Resident 1). This failure had the potential for Resident 1's injuries to worsen.
Findings:
During a review of Resident 1's Order Summary Report (OSR) dated 12/1/24, the OSR indicated, Cleanse sutures to back of head with NS (normal saline), pat dry and leave open to air. Every day shift.start date.11/28/24.monitor discoloration to chest for s/s (signs and symptoms) of worsening and notify MD (doctor of medicine) of changes.start date 11/27/24.monitor discoloration to right breast for s/s of worsening and notify MD of changes every shift for 14 days.start date 11/27/24.monitor discoloration to right under breast for s/s of worsening and notify MD of changes every shift for 14 days.start date 11/27/24.monitor discoloration to right upper arm for worsening and notify MD of changes every shift for 14 days.start date 11/27/24.monitor for pain before, during and after treatment to head. Every day shift.start date 11/28/24.monitor sutures on right side back of head for s/s of infection and notify MD of changes every shift. start date .11/27/24.
During a concurrent interview and record review on 12/2/24 at 1:32 p.m. with Director of Nursing (DON), Resident 1's Treatment Administration Record (TAR) dated November 2024 and December 2024, were reviewed. The TAR's indicated Resident 1's treatments were not administered on 11/30 day and evening shifts, and 12/1 evening shift. DON stated when the treatments were administered they should have been documented on the TAR. DON stated there was no way to know if the treatments were admnistered when it was not documented.
During a review of the facility's policy and procedure (P&P) titled, Wound Treatment Management dated 12/24, the P&P indicated, Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change.Treatments will be documented on the Treatment Administration Record or in the electronic health record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of two sampled resident's (Resident 1) fall assessment was accurate. This failure had the potential for staff to be unaware of Resident 1's fall risk.
Findings:
During a review of Resident 1's admission Record (AR) , dated 12/3/24, the AR indicated, Resident 1 was admitted on [DATE] with diagnosis including Dementia (the loss of thinking, remembering, and reasoning that interferes with a person's daily life and activities).
During a review of Resident 1's Cognitive Patterns (CP) dated 11/13/24, the CP indicated, BIMS (Brief Interview for Mental Status).04 (indicating severe cognitive impairment).
During a review of Resident1's S (Situation) B (Background) A (Appearance) R (Review and Notify) dated 11/24/24 at 7:20 p.m., the SBAR indicated, Falls.Resident complain to pain to head and right shoulder.send resident out to hospital.
During a review of Resident 1's FRE dated 11/24/24 at 8:01 p.m. (completed after the fall), the FRE indicated, Fall Risk Evaluation Score: 0.Fall Risk Evaluation Category: Low.mental status.oriented x3 (person, place, time).History of falls (past 3 months) . No falls in past 3 months.Gait/Balance/Ambulation.gait/balance normal.
During an interview on 12/9/24 at 1:02 p.m. with Director of Nursing (DON), DON stated after Resident 1's fall on 11/24/24, the FRE was inaccurate. DON stated Resident 1 was not oriented x3, had a fall in the past three months, and had a shuffling gait. DON stated the FRE score on 11/24/24 after the fall should have been greater than 10 indicating Resident 1 was a fall risk.
During a review of the facility's policy and procedure (P&P) titled, Fall Risk Assessment dated 12/24, the P&P indicated, The risk assessment will be completed by the nurse or designee upon admission, quarterly, or when a significant change is identified.The risk assessment will contain the following components.identify environmental hazards and individual risks, including the need for supervision.evaluate and analyze hazards and risks.

Based on observation, interview, and record review, the facility failed to follow its own policy and procedure for one for four sampled residents (Resident 1), when Resident 1 was not immediately assessed, and Attending Physician (AP) was not notified of Resident 1 ' s discoloration (bruise) to left inner corner eye, discoloration to right eyebrow, discoloration to bilateral upper extremities (region of the body that includes arm, forearm, and hand), discoloration to the back of left thigh. This failure resulted in a delay in treatment for Resident 1.
Findings:
During a concurrent observation and interview on 10/24/24 at 12:20 p.m. with Resident1, Resident 1 was in her room, sitting in a chair eating lunch. Resident 1's left outer eye was noted with red/purple/black discoloration measuring approximately 2.5 centimeters (cm) and left inner eye with red discoloration measuring approximately 1 cm. Resident 1 only smiled when spoken to.
During an interview on 10/24/24 at 12:52 p.m. with Director of Nurses (DON), DON stated on 10/21/24 at approximately 5 p.m. Licensed Vocational Nurse (LVN 1) reported Resident 1 having a new discoloration to left and right eye. DON stated upon further assessment, Resident 1 also had discoloration to the back of her left thigh and discoloration to bilateral upper extremities. DON stated all injuries looked really fresh. DON stated Resident
1's new discoloration to her left eye, discoloration to the back of her left thigh, and bilateral upper extremities were reported to LVN 2 by CNA 2 on 10/21/24 at the beginning of her shift (6:30 a.m.). DON stated LVN 2 did not assessed Resident 1, and did not notify Resident 1's AP.
During an interview on 10/24/24 at 1:06 p.m. with LVN 2, LVN 2 stated on 10/21/24 before breakfast trays were served, CNA 2 had reported Resident 1 having like minor or whatever in her left eye. LVN 2 stated Resident 1 was in bed with eyes closed and did not assessed Resident 1. LVN 2 stated she did not notify Resident 1's AP. LVN 2 stated, I didn ' t know we had to report every little thing.
During an interview on 10/30/24 at 11:32 a.m. with CNA 2, CNA 2 stated after clocking in to work on 10/21/24 at 6:30 in the morning, she saw Resident 1 walking in the hallway with discoloration to her left eye. CNA 2 stated she went directly to the nurse station and told LVN 2. CNA 2 stated while changing Resident 1 with CNA 3, they noticed new discolorations to bilateral upper extremities extending from wrist all the way up below the elbow. CNA 2 stated CNA 3 immediately reported the discoloration found on Resident 1's bilateral upper extremities to LVN 2.
During an interview on 10/30/24 at 12:01 p.m. with CNA 3, CNA 3 stated on 10/21/24, while changing Resident 1 with CNA 2, they noticed discoloration to bilateral upper extremities extending from wrist all the way up below the elbow. CNA 3 stated he immediately informed LVN 2.
During an interview on 10/30/24 at 11:48 a.m. with LVN 1, LVN 1 stated on 10/21/24 at 5:30 p.m. a full body assessment on Resident 1 was completed. LVN 1 stated Resident 1 had left and right eye discoloration, and discoloration to upper extremities. LVN 1 stated it was the facility practice to immediately assessed and notify AP of any new skin changes.
During a review of Resident 1's Progress Notes (PN), dated 10/21/24 at 9:21 p.m., the PN indicated, Heat [sic] to toe assessment performed. Discoloration noted to bilateral (right and left side) forearms. Discoloration to left eye. Redness noted to upper right eyebrow.
During a review of the facility's policy and procedure (P&P) titled, Change in a Resident ' s Condition or Status, dated 2/2021, the P&P indicated, 1. The nurse will notify the resident's attending physician or physician on call when there has been a (an): .d. significant change in the resident ' s physical/emotional/mental condition;. 3. Prior to notifying the physician or healthcare provider, the nurse will make a detailed observations and gather relevant and pertinent information. 8. The nurse will record in the resident ' s medical information relative to changes in the resident ' s medical/mental condition or status.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to:
1. Ensure one of four sampled residents (Resident 1) was free from physical abuse by facility staff (Certified Nursing Assistant-CNA 1). This failure resulted in Resident 1 sustaining discoloration (bruise) to left inner corner eye, discoloration to right eyebrow, discoloration to bilateral upper extremities (region of the body that includes arm, forearm, and hand), discoloration to the back of left thigh, a bald spot to the back of head, and hospitalization.
2. Ensure one of four sampled residents (Resident 3) was free from verbal abuse by facility staff (Licensed Vocational Nurse-LVN 3). This resulted in staff verbally abused Resident 3 and resulted in Resident 3 feeling angry and frustrated.
Findings:
1. During a review of Resident 1's admission Record (AR), dated 10/28/24, the AR indicated Resident 1's diagnoses included Alzheimer (a disease characterized by a progressive decline in mental abilities and Dementia (a progressive state of decline in mental abilities). Resident 1's annual Minimum Data Set (MDS-a federally mandated resident assessment tool) dated 10/11/24, indicated Resident 1 had a BIMS (Brief Interview for Metal Status-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 0 (score range from 0-7 severe impairment).
During a review of Resident 1's Progress Notes (PN), dated 10/21/24 at 9:21 p.m., the PN indicated, At Approx. (approximately) 1930 (7:30 p.m.) Resident (Resident 1) was sent to ER (Emergency Room) for further eval (evaluation) per MD (Medical Doctor) orders.Heat [sic] to toe assessment performed. Discoloration noted to bilateral (right and left side) forearms. Discoloration to left eye. Redness noted to upper right eyebrow. Approx. Nickel size abrasion to left shin.
During a review of the facility's Investigation Report (IR), dated 10/28/24, the IR indicated, This nurse immediately assessed (Resident 1) for reported skin changes at approximately 1730 (5:30 p.m.) and noted skin intact, with discoloration to left inner corner eye, discoloration to right eyebrow, discoloration to bilateral upper extremities, and to left posterior (back) thigh. (Resident 1) is unable to verbalize events surrounding discoloration due to cognition (process of knowing) impairment.During initial investigation (Resident 1) is noted to share roommate (Resident 2) with a BIMS of 14 (score range from 13-15 intact cognition), who (Resident 2) verbalizes that this morning (Resident 1) was being combative with the CNA (CNA 1) and was kicking and hitting the CNA, but the CNA was also hitting her back and had her against a corner holding her down.
During an interview on 10/24/24 at 12:11 p.m. with Administrator in Training (AIT), AIT stated a facility investigation was completed regarding the allegation of staff to resident abuse reported on 10/21/24 at 5:30 p.m. AIT stated Resident 2 had witnessed CNA 1 cornering her (Resident 1), holding her down, pulling her hair. AIT stated Resident 1 sustained injuries which included, discoloration to left and right eye, discoloration to bilateral upper extremities, discoloration to the back of left thigh, a bald spot to the back of head. AIT stated based on Resident 2's witnessed statement and Resident 1 ' s injuries, lead us to believe it could be caused from (CNA 1) doing that.
During a concurrent observation and interview on 10/24/24 at 12:20 p.m. with Resident 1, Resident 1 was in her room, sitting in a chair eating lunch. Resident 1's left outer eye was noted with red/purple/black discoloration measuring approximately 2.5 centimeters (cm) and left inner eye with red discoloration measuring approximately 1 cm. Resident 1 only smiled when spoken to.
During an interview on 10/24/24 at 12:52 p.m. with Director of Nurses (DON), DON stated on 10/21/24 at approximately 5 p.m. Licensed Vocational Nurse (LVN 1) reported Resident 1 having a new discoloration to left and right eye. DON stated upon further assessment, Resident 1 also had discoloration to bilateral upper extremities and discoloration to the back of her left thigh. DON stated all injuries looked really fresh. DON stated Resident 1 had diagnosis of Alzheimer and Dementia and was not able to verbalize how she sustained her new injuries. DON stated Resident 2 witnessed CNA 1 putting Resident 1 against the wall, holding her down, and pulled her hair. DON stated Resident 2 is alert and oriented, and cognitively (process of knowing) intact.
During a concurrent observation and interview on 10/24/24 at 1:26 p.m. with Resident 2, Resident 2 was in her room, sitting in her bed. Resident 2 stated on 10/21/24 at approximately 6 a.m. CNA 1 entered the room to provide care for Resident 1. Resident 2 stated the privacy curtain between the beds was halfway open and saw Resident 1 with eyes closed, when CNA 1 pulled her clothes down and attempted to change Resident 1. Resident 2 stated Resident 1 allowed CNA 1 to remove and change her top shirt but became combative. Resident 1 was kicking CNA 1 and refusing to change her pants. Resident 2 stated CNA 1 held Resident 1 with one hand and managed to pull Resident 1's pants off. Resident 2 stated she saw CNA 1 holding Resident 1 on the bed, pulled her hands by the wrist, got her up, placed her in the corner of the room, and pulled Resident 1 by the hair. Resident 2 stated Resident 1 continued to fight to be released.
During an interview on 10/30/24 at 11:32 a.m. with CNA 2, CNA 2 stated on 10/21/24 at 6:30 in the morning, she saw Resident 1 walking in the hallway with discoloration to her left eye. CNA 2 stated while changing Resident 1 with CNA 3, they noticed discoloration to bilateral upper extremities extending from wrist all the way up below the elbow. CNA 2 stated Resident 1's discoloration to left and right eye, discoloration to her bilateral upper extremities found on 10/21/24 were not there on 10/20/24. CNA 2 stated Resident 1's discoloration to her left eye looked like someone punched her in the eye and the discoloration on bilateral upper extremities could be caused from being held too tight or pressing on her like in a forceful way.
During an interview on 10/30/24 at 11:48 a.m. with LVN 1, LVN 1 stated on 10/21/24 a full body assessment on Resident 1 was completed. LVN 1 stated Resident 1 had left and right eye discoloration and discoloration to bilateral upper extremities. LVN 1 stated the discoloration on both upper extremities would not have been caused by bumping into something. LVN 1 stated Resident 1's left and right eye discoloration and discoloration to her bilateral upper extremities found on 10/21/24, were not there on 10/20/24. LVN 1 stated Resident 1 was transferred to the acute hospital for further evaluation.
During an interview on 10/30/24 at 12:01 p.m. with CNA 3, CNA 3 stated on 10/21/24, during breakfast, he noticed Resident 1's left eye and right with red discoloration. CNA 3 stated while changing Resident 1 with CNA 2, they noticed discoloration to bilateral upper extremities. CNA 3 stated, Really bad discoloration, like purple from wrist to below elbow. CNA 3 stated while combing Resident 1's hair, he noticed bald spot in the back of her (Resident 1) head that had not been there before.
During a review of Resident 1's Emergency Documentation (ED-acute hospital), dated 10/21/24 at 9:12 p.m. the ED indicated Resident 1 had left periorbital (tissues around the eye) ecchymosis (bruise, discoloration) and bilateral forearm bruising.
2. During an interview on 10/30/24 at 10:20 a.m. with DON, DON stated on 10/24/24, Resident 3 sent her a text message alleging LVN 3 of calling Resident 3 names including drug addict.
During a review of Resident 3's admission Record (AR), dated 10/31/24, the AR indicated Resident 3's diagnoses included Schizoaffective disorder (a mental health condition with symptoms including hallucination [false perception of an object or event that involves one of the senses, such as sight, sound, smell, touch or taste] and mania [period of extreme mood swings, high energy]) Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). The admission MDS dated [DATE], indicated under BIMS a score of 15 (cognitively intact).
During a concurrent observation and interview on 10/30/24 at 10:53 a.m. with Resident 4, Resident 4 was in his room sitting in a wheelchair. Resident 4 stated on 10/24/24, he was headed to the day room to watch Thursday night football with Resident 3 when LVN 3 went behind Resident 3, started pulling on his wheelchair, and telling Resident 3 he was not allowed to go into the day room. Resident 4 stated Resident 3 became upset at LVN 3. Resident 4 stated LVN 3 was doing most of the yelling calling Resident 3 a drug addict, pill seeker.
During a review of Resident 4 quarterly MDS dated [DATE], the MDS indicated under BIMS a score of 15 (cognitively intact).
During a concurrent observation and interview on 10/30/24 at 11:03 a.m. with Resident 3, Resident 3 was in the activity room, sitting in a wheelchair. Resident 3 stated on 10/24/24, he was entering the day room to watch Thursday night football with Resident 4 when LVN 3 told him he was not allowed to go in the day room. Resident 3 stated LVN 3 then began calling him a drug addict, pill seeker, just calling me names. Resident 3 stated he felt angry and frustrated. Resident 3 stated, I ' m here to get better, I ' m not here to be called names.
During an interview on 10/30/24 at 4:25 p.m. with LVN 4, LVN 4 stated she was at the nurse station when she saw LVN 3 grabbed Resident 3 ' s wheelchair away from the day room, saying he was not allowed to go in the day room. LVN 4 stated she heard LVN 3 calling Resident 3 a drug addict, a pill seeker. LVN 4 stated calling Resident 3 names was not appropriate and should not be done.
During an interview on 10/31/24 at 9 a.m. with Director of Staff Development (DSD), DSD stated calling resident names including drug addict, pill seeker is not appropriate and a form of verbal abuse.
During a review of the facility IR dated 10/28/24, the IR indicated, At approx. [sic] 20:26 (8:26 p.m.) (Resident 3) made an allegation .that she (LVN 3) .pulled me away from the day room, calling me a drug addict.
During a review of the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, dated 4/2021, the P&P indicated, Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not acquired to treat the resident's symptoms. The resident abuse, neglect, and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: 1. Protect residents from abuse, neglect, exploitation, or misappropriation of property by anyone including, but not necessarily limited to: a. facility staff;

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure discharge instructions were discussed with the responsible party (RP) of one of three sampled residents (Resident 1) when Resident 1 was discharged home. This failure resulted in the RP of Resident 1 being unaware of how to care for Resident 1 and Resident 1 being admitted to the hospital.
Findings:
During a review of the Progress Notes (PN), dated 10/18/24 at 8:03 p.m., the PN indicated, At 1125 resident discharges home to family.admitted for short term rehabilitation; PT (Physcial Therapy)/OT (Occupational Therapy), ST (Speech Therapy) and wound care. Past medical hx (history) of hemiplegia (condition that causes severe weakness in the muscles on one side of the body, often affecting the arm, leg, and face) % [sic] hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles), muscle weakness, contracture of muscle, and pressure ulcer (injury to the skin and underlying tissue resulting from prolonged pressure on the skin) of left and lower back stage four (most severe type of pressure ulcer that extends to muscle, tendon, or bone). Resident was transported via medical transport, accompanied by transport attendant. All personal belongings, medication, medication list was taken by resident, inventory signed, and items accounted. Resident educated in the importance or following up with primary (physician) provided in a timely matter. Education in medication administration provided.
During a review of Resident 1 ' s admission Record (AR), dated 11/15/24, the AR indicated Resident 1 was admitted on [DATE] with diagnoses.hemiplegia and hemiparesis following cerebral infarction (medical condition that occurs when blood flow to the brain is blocked, causing brain tissue to die) affecting right dominant side, aphasia (difficulty speaking) following cerebral infarction.dysphagia (difficulty swallowing), oropharyngeal phase (active phase of swallowing, when food is moved from the mouth to the upper esophagus).cognitive communication deficit.pressure ulcer of left lower back, stage 4, pressure-induced deep tissue damage of left heel.
During a review of Resident 1 ' s Minimum Data Set (MDS-resident assessment tool), dated 10/18/24, the MDS indicated, BIMS (Brief Interview for Mental Status) .04 (0-7 suggests severe cognitive impairment)
During a review of Resident 1 ' s Discharge Summary/Instructions (DSI), dated 10/15/24, the DSI indicated, Date of Discharge 10/18/24.Recapitulation of Stay Resident admitted for short stay rehab (rehabilitation) PT/OT? [sic] ST, and wound care.Skin condition.right buttock.left buttock.discharge location. Home/family assist.Wound care instructions.Education provided.Acknowledgements.I understand the above discharge instructions.Patient/Representative Signature.(document was unsigned).Completing Nurse Acknowledgements.(document was unsigned).
During a review of Resident 1 ' s ED (Emergency Department) Physician Notes (EDPN) dated 10/20/24 at 2:53 p.m., the EDPN indicated, (Resident 1) is a [AGE] year old female who presents due to family concern over sacral wound. She was recently here in the hospital admitted for sacral (triangular bone at the base of the spine) decubitus (bed sore) wound.and then discharged to a skilled nursing facility. She left the skilled nursing facility yesterday and was discharged home. Her husband became very overwhelmed because he did not know how to care for her and was intimidated by the wound.Skin: wounds large sacral decubitus wound stage 3 (deep wound that involves full thickness tissue loss, but does not expose bone, tendon, or muscle) and a portion that appears to be stage 4 (deep wound that extends to muscle, tendon, or bone).
During an interview on 11/14/24 at 12:45 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated when a resident discharges home the discharge paperwork should be discussed and provided to the resident or the RP who is responsible for providing the care, if the resident is unable to care for themselves. LVN 1 stated when a resident was sent home via transport the discharge instructions should be discussed over the phone with the care provider and a copy placed in the resident ' s belongings.
During an interview on 11/14/24 at 12:55 p.m. with Director of Nursing (DON), DON stated when Resident 1 was discharged on 10/18/24, LVN 2 went over the discharge instructions with Resident 1 and did not discuss them with the RP. DON stated Resident 1 was a BIMS of 4 and would not have understood the discharge instructions provided. DON stated LVN 2 should have called Resident 1 ' s RP and discussed the discharge medications and wound treatments.
During an interview on 11/15/24 at 9:10 a.m. with Family Member (FM) 1, FM 1 stated Resident 1 was discharged home via a transport van from the facility on 10/18/24. FM 1 stated staff did not speak to him regarding discharge instructions, or the care Resident 1 required upon discharge. FM 1 stated Resident 1 showed up at the house with papers that only contained medications that Resident 1 was receiving. FM 1 stated Resident 1 was home for one day and had to be transported by ambulance to the hospital due to an infected wound. FM 1 stated he was unaware that Resident 1 had a wound that needed to be treated.
During an interview on 11/15/24 at 11:17 a.m. with Social Service Director (SSD), SSD stated Resident 1 was admitted to the facility for short term rehabilitation and the plan was for Resident 1 to return home with the RP. SSD stated when discharge plans were discussed with the RP, (SSD) was unaware Resident 1 had pressure ulcers that needed treatment and home health was not set up prior to discharge. SSD stated it was the nurse ' s responsibility to provide the discharge instructions to the RP.
During a review of the facility ' s policy and procedure (P&P) titled Discharge Summary and Plan dated 10/22, the P&P indicated, The discharge summary includes a recapitulation of the resident ' s stay at the facility and a final summary of the resident ' s status at the time of the discharge.The discharge summary shall include a description of the resident ' s.ability to perform activities of daily living including: bathing, dressing and grooming, transferring and ambulating, toilet use, eating, and using speech, language, and other communication systems.special treatments or procedures.activities potential (the ability and desire to take part in activity pursuits which maintain or improve physical, mental, and psychosocial well-being).The resident/representative is involved in the post-discharge planning process and informed of the final post-discharge plan.

Based on interview and record review, the facility failed to follow physician orders when the physician was not notified of elevated blood sugars for one of three sampled residents (Resident 1) . This failure had the potential for Resident 1 to experience complications.
Findings:
During a review of Resident 1 ' s Order Summary Report (OSR), dated 10/1/24, the OSR indicated, Fingerstick Blood Sugar Monitoring three times a day notify MD (physician) if blood sugar is above 300 or below 70mg/dl (milligrams/deciliter-unit of measurement).order date 9/25/24.
During a review of Resident 1 ' s Medication Administration Record (MAR), dated 10/2024, the MAR indicated,
10/1 BS (blood sugar) 0800 (8 a.m.) 349
10/2 BS 0800 349
10/3 BS 0800 339
10/4 BS 0800 350, 1100 (11 am) 312, 1600 (4 p.m.) 355
10/5 BS 0800 326, 1100 348
10/6 BS 0800 329, 1600 (4 pm) 333
10/7 BS 0800 349, 1600 303
10/8 BS 0800 302
10/9 BS 1600 302
10/10 BS 1100 347
10/11 BS 1600 409
10/12 BS 1100 343
10/13 BS 0800 347, 1100 338
10/14 BS 0800 347
10/15 BS 0800 329
10/16 BS 0800 349, 1600 344.
During a concurrent interview and record review on 10/17/24 at 1:04 p.m. with Assistant Director of Nursing (ADON), Resident 1 ' s clinical record was reviewed. There was no evidence of the physician being notified of the blood sugars over 300. ADON stated the physician should have been notified every time Resident 1 ' s blood sugar was over 300.
During a review of the facility ' s policy and procedure (P&P) titled Diabetes – Clinical Protocol dated 2020, the P&P indicated, The Physician will order desired parameters for monitoring and reporting information related to blood sugar management.The staff will incorporate such parameters into the Medication Administration Record and care plan.

Based on observation, interview, and record review, the facility failed to ensure medications were properly stored. This failure resulted in unidentified pills being in the bottom of the medication carts.
Findings:
During a concurrent observation and interview on 10/15/24 at 3:03 p.m. with Licensed Vocational Nurse (LVN) 1, medication cart 2 was observed. In drawers three and four there were several loose pills laying in the bottom of the drawers. LVN 1 stated the pills should not be loose in the bottom of the cart.
During a concurrent observation and interview on 10/15/24 at 3:07 p.m. with Assistant Director of Nursing (ADON), ADON was unable to identify the loose pills and stated medications were not supposed to be loose in the drawers of the medication carts.
During a concurrent observation and interview on 10/15/24 at 3:15 p.m. with LVN 2, medication cart 3 was observed. There were several loose pills laying in the bottom of drawers two and three. LVN 2 stated the pills should not be loose in the bottom of the drawers.
During a review of the facility policy and procedure (P&P) titled, Medication Labeling and Storage dated 2001, the P&P indicated, Medications and biologicals are stored in the packaging, containers or other dispensing systems in which they are received.

Based on observation, interview, and record review, the facility failed to ensure the therapeutic menu was followed for three of five sampled residents (Resident 4, Resident 5, and Resident 6). This failure had the potential for unmet nutritional needs.
Findings:
During a review of the Fall Menu (FM) dated 9/18/24, the FM indicated, Chicken cacciatore, sauce, pasta with garlic and herbs, broccoli and cauliflower, parsley sprig, Italian green salad, dressing, cranberry crunch square and milk were to be served for lunch.
1. During a review of Resident 4 ' s Diet Card (DC), (undated), the DC indicated, Diet order: Regular Texture.
During a concurrent observation and interview on 10/15/24 at 12:23 p.m. in Resident 4 ' s room, Resident 4 ' s lunch tray was at bedside. On the lunch tray there was a plate that contained pasta, cauliflower and mechanical soft (a texture-modified diet that limits foods that are difficult to chew or swallow) chicken cacciatore. There was a dessert and salad on the side. Resident 4 stated the kitchen ran out of regular texture chicken cacciatore entrée and served her a mechanical soft texture. Resident 4 stated she did not know what it was and refused to eat it.
During a concurrent observation and interview on 10/15/24 at 12:43 p.m. with Certified Nursing Assistant (CNA) 1, in Resident 4 ' s room. CNA 1 confirmed the findings and stated Resident 4 was provided a mechanical soft entrée due to the kitchen running out of the regular texture entrée.
2. During a review of Resident 5 ' s DC, (undated), the DC indicated, Diet order: Regular Texture.
During a concurrent observation and interview on 10/15/24 at 12:44 p.m. with CNA 1, in Resident 5 ' s room, Resident 5 ' s lunch tray was at bedside. On the lunch tray there was a plate that contained pasta, cauliflower, and mechanical soft chicken cacciatore entree. There was a dessert on the side and no salad was provided. CNA 1 stated the kitchen ran out of the regular texture entrée and served Resident 5 mechanical soft texture entree.
3. During a review of Resident 6 ' s DC, (undated), the DC indicated, Diet order: Chopped Meats Texture, Large Portion.
During a concurrent observation and interview on 10/15/24 at 12:51 p.m. with Resident 6, in Resident 6 ' s room, Resident 6 was eating her lunch. Resident 6 ' s lunch tray contained chicken cacciatore, broccoli pasta and a dessert. There was no salad provided to Resident 6. Resident 6 stated she loved salad.
During an interview on 10/15/24 at 12:55 p.m. with CNA 2, CNA 2 stated Resident 6 did not receive salad on her tray, and she should have been served salad.
During an interview on 10/15/24 at 1:33 p.m. with Dietary Supervisor (DS), DS stated the regular texture chicken cacciatore ran out and the mechanical soft entrée was served to the regular texture diets. DS stated the regular texture diet should have been served the regular texture chicken cacciatore and salad should have been served to all the residents.
During a review of the facility ' s policy and procedure (P&P) titled, Menu Planning dated 2023, the P&P indicated, The menus are planned to meet nutritional needs of residents in accordance with established national guidelines, Physician ' s orders and, to the extent medically possible.Menus are written for regular and therapeutic diets in compliance with the diet manual.

Based on observation, interview, and record review, the facility failed to implement a care plan for one of four sampled residents (Resident 1) when the hospital medical records were not requested after Resident 1 was re-admitted from the hospital. This failure resulted in the facility being unaware of Resident 1 ' s weight bearing status and the need for a follow up appointment, placing Resident 1 at risk for re-injury and a delay in care.
Findings:
During an observation on 10/17/24 at 10:35 a.m. in the hallway, Resident 1 was ambulating with a four wheeled walker.
During a review of Resident 1 ' s Progress Notes (PN), dated 10/4/24 at 11:05 a.m., the PN indicated, Date of Incident: 10/3/24.Unwitnessed fall.CNA (certified nursing assistant) was notified that resident fell on the floor.resident was noted to be on the floor trying to get herself back up.IDT (Interdisciplinary Team-a collaborative approach to patient care that involves multiple health professionals working together to provide comprehensive care) met and determined that resident while ambulating too fast with her walker, resident may have tripped over her walker and fell.Order put in for x-ray of the hip, pending results.
During a review of Resident 1 ' s Radiology Results Report (RRR), dated 10/6/24, the RRR indicated, Resident 1 had a fracture (broken bone) involving right subcapital femur (partial break in thigh bone) with no displacement (moving of something from its position). The age of the fracture (broken bone) is acute (sudden).
During a review of Resident 1 ' s PN, dated 10/7/24, the PN indicated IDT meeting follow up.(Resident 1) returned to facility from (hospital name) with NNO (no new orders).New interventions.Ward clerk to request medical records from the acute.
During a review of Resident 1 ' s Care Plan (CP), dated 10/4/24 the CP indicated, (Resident 1) had an actual fall.r/t (related to) poor balance, unsteady gait, and tripping over the walker while ambulating.Interventions.x-ray of the hip.Date initiated: 10/4/24.send out to the acute for further evauations (sic) Date initiated: 10/7/24.request medical records from acute (hospital) Date initiated 10/7/24.
During an interview on 10/17/24 at 11:15 a.m. with [NAME] Clerk (WC), WC stated she did not have the hospital records for Resident 1 and would have to request them.
During a concurrent interview and record review on 10/17/24 at 1:50 p.m. with ADON, Resident 1 ' s Emergency Department Discharge Instruction (EDD), dated 10/6/24 was reviewed. The EDD indicated, .Ortho (orthopedist-doctor that treats injuries and diseases involving muscles, bones, joints, ligaments, and tendons) recommends keeping the patient (Resident 1) non weight bearing (leg should not touch the floor or support any body weight), no splinting (external device to stop movement), and outpatient follow up in his clinic in one week. ADON stated the hospital records were not received until 10/17/24 (11 days later) at 1:10 p.m. orders for non-weight bearing and ortho follow up in one week were not done.
During a review of the facility ' s policy and procedure (P&P) titled, Care Area Assessments, dated November 2019, the P&P indicated, 2. The care area assessments (CAAs) process consists of the following steps: .e. Document interventions on the care plan: (2) Include recommendations for monitoring and follow-up time frames.

Based on interview and record review, the facility failed to ensure the physician was notified of a change of condition when one of four sampled residents (Resident 1) had a rash. This failure had the potential for the rash to worsen.
Findings:
During a review of the Shower Day Skin Inspection (SDSI), dated 8/5/24, the SDSI indicated, Skin Problem.Yes.Rash.All over body.8/5/24.(Nurse Signature).
During a review of the Shower Day Skin Inspection (SDSI), dated 8/8/24, the SDSI indicated, Skin Problem.Yes.Rash.All over body.8/8/24.(Nurse Signature).
During a review of Resident 1 ' s Progress Notes (PN), dated 8/13/24 (8 days after the rash was identified) at 6:06 p.m., the PN, documented by Infection Preventionist (IP) indicated, (Physician name) was consulted by this writer regarding her rash to her stomach.
During a concurrent interview and record review, on 8/27/24 at 4:21 p.m. with Infection Preventionist (IP), Resident 1 ' s Progress Notes (PN) were reviewed. There was no documentation indicating the physician was notified of Resident 1 ' s rash until 8/13. IP stated she notified Resident 1's physician of the rash on 8/13 and the physician should have been notified when the rash was identified on 8/5/24.
During a review of the facility policy and procedure (P&P) titled Change in a Resident ' s Condition or Status dated 2/21, the P&P indicated, The nurse will notify the resident ' s attending physician.when there has been a(an).significant change in the resident ' s physical/emotional/mental condition.a significant change of condition is a major decline or improvement in the resident ' s status that.will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions.

Based on interview and record review, the facility failed to follow its policy and procedure for one of three sampled residents (Resident 1) when a laboratory test was not completed. This failure had the potential for the facility to be unaware of health issues for Resident 1.
Findings:
During a review of Resident 1 ' s Progress Notes (PN), dated 5/22/24 at 11:37 a.m. the PN indicated, IDT (Interdisciplinary Team-a group of health care professionals with various areas of expertise who work together toward the goals of their clients) Risk Management Follow Up.As staff heard loud voices coming from room [Resident 1 and Resident 2 ' s room]. Staff ran to room and saw [Resident 1] was [sic] standing at the end of his bed exchanging voices with other [Resident 2].Staff noticed a skin tear to [Resident 1] ' s right lower eyelid.New Interventions put into place.psych (psychological) eval (evaluation).
During a review of Resident 1 ' s Psychiatric F/U (follow up) Note (PFUN), dated 5/22/24, the PFUN indicated, Plan.Will recommend labs [laboratory] (CBC (complete blood count), CMP (comprehensive metabolic panel-14 panel blood test used to tell how the body is using food and energy).
During a concurrent interview and record review, on 5/29/24 at 12 p.m. with Director of Nursing (DON), Resident 1 ' s clinical record was reviewed. DON was unable to find documentation the recommended labs were completed. DON stated the labs should have been completed.
During a review of the facility ' s policy and procedure (P&P) titled, Lab and Diagnostic Test Results - Clinical Protocol dated 2018, the P&P indicated, The physician will identify and order diagnostic and lab testing based on the resident ' s diagnostic and monitoring needs.The staff will process test requisitions and arrange for tests.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure weekly wound assessments were done for one of one sampled resident (Resident 39). This failure had the potential to result in the inability to determine the healing progress of current wounds.
Findings:
During a concurrent interview and record review on 4/18/24 at 11:58 a.m. with Licensed Vocational Nurse (LVN) 1, Resident 39's Skin & Wound Evaluation (SWE), [undated] was reviewed. LVN 1 stated Resident 39 was admitted on [DATE] with a wound on the left hand first and second fingers. LVN 1 stated no weekly wound assessments were done for the past four weeks in March and and there was only a wound assessment done on 4/3/24.
During an interview on 4/18/24 at 2:40 p.m. with Director of Nursing (DON), DON stated weekly wound assessments should be done on residents with wounds.
Facility policy and procedure related to weekly wound assessments was requested; none was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure Physicians provided informed consents for four of four sampled residents (Resident 29, Resident 35, Resident 54, Resident 72, and Resident 143) prior to administration of psychotropic medications (used to treat mental health disorders) and ensure the consent and acknowledgement of the informed consents by the resident or the resident's representative were documented on the Informed Consent Form (ICF).
This failure violated patients' rights to be fully informed of their treatment and medications.
Findings:
During a concurrent interview and record review on 4/16/24, at 2:21 p.m., with Licensed Vocational Nurse (LVN) 1, Resident 29's ICFs, dated 7/24/23, 11/823, and 1/17/24, were reviewed. The ICF, dated 7/24/23, indicated, Latuda (medication to treat a mental health disorder) 20 mg (milligram) one tablet daily for schizophrenia (mental health disorder) manifested by visual hallucinations. The ICF, dated 11/8/23, indicated, Cymbalta (medication to treat a mental health disorder, and fibromyalgia [widespread musculoskeletal pain]) oral capsule delayed release 30 mg one capsule by mouth once a day for depression (persistent feeling of sadness and loss of interest) as manifested by verbalization of feeling depressed. The ICF, dated 1/17/24, indicated, Ativan (anxiety medication) 0.5 mg give one tablet by mouth at bedtime every other day for anxiety manifested by excessive worry over health concerns. All three ICF forms for Resident 29 under the section I have obtained informed consent from indicated the responsible party was checked and the name of the responsible party was handwritten. The forms did not have an actual signature of the responsible party. All three ICF forms for Resident 29 indicated the signature of the nurse was under the section verification of informed consent by facility representative. The ICF, dated 1/17/24, did not have the date the physician signed the informed consent as having obtained the informed consent. LVN 1 stated it was the nurse who called the family to explain the risk, benefits, and alternatives, and once the nurse received the physician's order, the nurse documented that he or she had obtained informed consent. LVN 1 stated the physician did not explain the risk, benefit, and alternatives (RBAs); the nurses discussed that (RBAs) with the family or the resident's representative.
During an interview on 4/16/24 at 2:25 p.m. with the Clinical Resource Nurse, (CRN) joined the discussion about informed consent and stated the physicians do not do the Informed Consents. CRN asked how can the physicians call everyone to explain the risk, benefits, and alternatives? CRN stated, The nurses here are professionals. They could explain the risks, benefits, and alternatives to the family.
During a concurrent interview and record review on 4/16/24, at 2:30 p.m. with LVN 1, Resident 35's ICFs, dated 9/10/23, and 11/20/23, were reviewed. The ICF, dated 9/10/23, indicated, Abilify (medication to treat a mental health disorder) 10 mg one tablet by mouth daily for schizophrenia manifested by aggression and striking out. The Responsible Party was checked but there was no name of the responsible party and actual signature of the responsible party who gave the consent on the ICF. The nurse signed verification of the informed consent on 9/10/23. The physician who obtained the informed consent signed the ICF on 9/11/23, one day after the informed consent was discussed by the physician with the responsible party. LVN 1 stated the nurses call the responsible party and explain the risks, benefits, and alternatives. LVN 1 stated the physician was asked to sign the form. The ICF, dated 11/20/23 indicated, Ativan 0.5 mg give one tablet two times a day for anxiety manifested by anxiousness causing resident to strike out. The section I have obtained informed consent from indicated 'Other' and the word guardian was handwritten. The ICF did not have the name of the guardian and the actual signature of the guardian on the ICF. The form contained a signature of a physician but there was no name of the physician. The form indicated the Director of Nursing signed the verification of the informed consent. LVN 1 stated there should be two nurses' signature if this was a consent obtained over the phone.
During a concurrent interview and record review on 4/16/24 at 2:32 p.m. with LVN 1, Resident 72's ICF dated 3/24/23, 8/20/23, and 11/10/23, were reviewed. The ICF, dated 3/24/23, indicated, Buspirone (anxiety medication) 15 mg PO (by mouth) BID (two times a day) for anxiety manifested by pacing to the point of exhaustion. The responsible party was checked and the name of the responsible party who gave the consent was handwritten on the form. The form contained a signature of a physician but there was no name of the physician. The ICF, dated 8/20/23, indicated, Depakote (used to treat seizure disorders and certain psychiatric conditions) 125 mg one tablet every 12 hours by mouth for psychosis (loss of contact with reality; may have false beliefs about what is taking place) manifested by paranoia (an extreme fear and distrust of others), verbalizing someone is going to hurt her. The responsible party was checked, and the name of the person was handwritten on the side. LVN 1 stated there was no actual signature of the responsible party on the form. The ICF, dated 11/10/23, indicated, Ativan 0.5 mg give four times a day for anxiety manifested by inability to stay still. The ICF did not indicate the name of the responsible party or the physician who obtained the informed consent. LVN 1 stated the form was incomplete.
During a concurrent interview and record review on 4/16/24 at 2:33 p.m. with LVN 2, Resident 143's ICF, dated 4/14/24 was reviewed. The ICF indicated, Sertraline (medication to treat a mental health disorder) 50 mg take one tablet by mouth daily for depression manifested by verbalization of health decline. Trazodone (medication to treat major depressive disorder) 50 mg take one tablet by mouth at night for depression manifested by failure to thrive. On both ICFs, the responsible party was marked but there was no name and actual signature of the responsible party. The nurse signed and verified informed consent was obtained. There was no physician signature as having discussed and obtained informed consent with the resident's representative. LVN 2 stated we were waiting for the physician to come and sign the form. LVN 2 stated he did the informed consent; LVN 2 stated he spoke with the responsible party while in the facility during Resident 143's admission on [DATE].
During a concurrent interview and record review on 4/16/24 at 2:35 p.m. with LVN 1, Resident 143's Medication Administration Record (MAR), dated 4/2024, was reviewed. The MAR indicated Resident 143 received Sertraline HCl 50 mg on 4/15/24 and 4/16/24 at 8 a.m. and Trazodone 50 mg one tablet on 4/15/24 at 8 p.m.
During a review of the facility's policy and procedure (P&P) titled, Health Information Record Manual, dated 5/11/22, the P&P indicated, Informed Consent: For residents with antipsychotic medication, prescription, orders, or increase to an existing dose, the physician must obtain informed consent from the capable resident. If the resident is deemed by the physician not capable, informed consent may be obtained from the resident's representative.
During a review of the facility's P&P titled, Informed Consent, [undated], the P&P indicated, PURPOSE To assure that the resident's health record contains documentation that the resident gave informed consent prior to the initiation or administration of psychotherapeutic drugs, physical restraints, or the prolonged use of a device that may lead to the inability to regain use of a normal bodily function. POLICY Before initiating the administration of psychotherapeutic drugs . staff shall verify that the resident's health record contains documentation that the resident has given informed consent for the proposed treatment or procedure. REQUIREMENTS 1 Physician requirements a. It is the responsibility of the attending physician to determine what information a reasonable person in the resident's condition and circumstances would consider material to a decision to accept or refuse a proposed treatment or procedure. b. Information that is commonly appreciated need not be disclosed. c. The disclosure of the material information and obtaining informed consent shall be the responsibility of the physician.

Based on observation, interview, and record review, the facility failed to ensure four of 46 sampled residents (Resident 44, Resident 242, Resident 39, and Resident 4) were assessed and provided with the appropriate call light type to call staff when needed. This failure had the potential for residents' needs not being met.
Findings:
During an observation on 4/15/24 at 9:25 a.m. in Resident 44's room, Resident 44's call light was on the floor.
During an observation on 4/15/24 at 9:28 a.m. in Resident 242's room, Resident 242's call light wire was not attached to the wall and the call light was not in Resident 242's reach.
During an observation on 4/15/24 at 9:30 a.m. in Resident 39's room, Resident 39's call light was on the oxygen concentrator (a device that delivers oxygen) and was not in resident's reach. Upon pushing the button, the call light was not working.
During a concurrent observation and interview on 4/15/24 at 9:38 a.m. with Director of Maintenance (DM), in Resident 44, Resident 242, and Resident 39's shared room, Resident 44's call light was on the floor, Resident 242's call light was unplugged and not within Resident 242's reach, and Resident 39's call light was on the oxygen concentrator. No service bells were observed in the room. DM checked the functionality of the call lights and stated the call lights were not working. DM stated the residents should have a service call bell to call for assistance.
During an observation on 4/15/24 at 9:46 a.m. in Resident 4's room, Resident 4's call light was not within reach.
During an interview on 4/15/24 at 9:50 a.m. with Certified Nursing Assistant (CNA) 4, CNA 4 stated Resident 4's call light was on the floor.
During an interview on 4/15/24 at 10:04 a.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated, Call light should be in reach at all times.
During a review of the facility's policy and procedure (P&P) titled, Call System, Resident, dated 2022, the P&P indicated, Residents are provided with a means to call for assistance through a communication system that directly calls a staff member or a centralized work station. 1. Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor. 3. The resident call system remains functional at all times.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, facility failed to:
1. Ensure 10 of 13 sampled residents (Resident 54, Resident 80, Resident 29, Resident 143, Resident 72, Resident 36, Resident 78, Resident 45, Resident 82, and Resident 24) or residents' representatives were provided information and allowed to formulate advance directives (AD, a written document that tells the health care providers who should speak for you and what medical decisions they should make if you become unable to speak for yourself). This failure had the potential to result in the residents' wishes or health choices to not be honored.
2. Ensure the Physician's Order for Life Sustaining Treatment (POLST-a medical order form that records patient treatment wishes so emergency personnel know what treatments the patient wants in the event of a medical emergency) for two of two sampled residents (Resident 143 and Resident 142) was ordered by the physician prior to having Resident 143 and Resident 142's representatives sign the documents.
Findings:
1 a. During a concurrent interview and record review on [DATE] at 10:15 a.m. with Licensed Vocational Nurse (LVN) 3, Resident 54's AD was reviewed. LVN 3 was unable to provide documentation AD information was offered to Resident 54 or the resident's representative. LVN 3 stated Resident 54 did not have an advance directive.
1 b. During a concurrent interview and record review on [DATE] at 10:47 a.m. with LVN 3, Resident 80's AD was reviewed. LVN 3 was unable to provide documentation AD information was offered to Resident 80 or the resident's representative. LVN 3 stated Resident 80 did not have an advance directive.
1 c. During a concurrent interview and record review on [DATE] at 10:55 a.m. with LVN 3, Resident 29's AD was reviewed. LVN 3 was unable to provide documentation AD information was offered to Resident 29 or the resident's representative. LVN 3 stated Resident 29 did not have an advance directive.
1 d. During a concurrent interview and record review on [DATE] at 11:16 a.m. with LVN 3, Resident 143's AD was reviewed. LVN 3 was unable to provide documentation AD information was offered to Resident 143 or the resident's representative. LVN 3 stated Resident 143 did not have an advance directive.
1 e. During a concurrent interview and record review on [DATE] at 1:30 p.m. with LVN 3, Resident 72's AD was reviewed. LVN 3 was unable to provide documentation AD information was offered to Resident 72 or the resident's representative. LVN 3 stated Resident 72 did not have an advance directive.
1 f. During a concurrent interview and record review on [DATE] at 8:51 a.m. with Clinical Resource Nurse (CRN), Resident 36 AD, dated [DATE], and Resident 78's AD, dated [DATE] were reviewed. The ADs for both Resident 36 and Resident 78 were not completed and were not signed. CRN stated the forms should have been completed and signed.
1 g. During a concurrent interview and record review on [DATE] at 12:18 p.m. with Director of Nursing (DON), the Advance Directive Acknowledgement (ADA) for Resident 45, dated [DATE] was reviewed. DON stated this is not a complete advance directive; it is missing a physician signature. DON stated it should be filled out completely.
1 h. During a concurrent interview and record review on [DATE] at 12:19 p.m. with DON, ADA for Resident 82, dated [DATE] was reviewed, DON stated this advance directive is not filled out and has no signatures. DON stated it is not complete and should be completed.
1 i.During a concurrent interview and record review on [DATE] at 12:20 p.m. with DON, ADA for Resident 24, dated [DATE] was reviewed, DON stated, This is not an advanced directive, it is their wishes. DON stated it is our policy to have a documented advanced directive on file or at least offer it to all residents. DON stated the ADA was missing physician signatures and not from this facility.
2 a. During a concurrent interview and record review on [DATE] at 11:16 a.m. with LVN 3, Resident 143's POLST, dated [DATE], was reviewed. The POLST indicated the physician had not discussed, wrote the order, nor completed the POLST. The POLST indicated it had already been signed by Resident 143's representative. LVN 3 stated, Because the patient representative was here, we let the patient representative sign the POLST without the MD order. We got the report the patient was Do Not Resuscitate (DNR-a medical order issued by a physician that directs healthcare providers not to administer cariopulmonary resuscitation [CPR]) from the hospital.
2 b. During a concurrent interview and record review on [DATE] at 2:39 p.m. with LVN 2, Resident 142's POLST, dated [DATE], was reviewed. The POLST indicated, The POLST had not been signed by the physician. The POLST indicated, the form had been completed and Resident 142's representative had already signed the form. LVN 2 stated we were waiting for the Physician to come and sign the form.
During a review of Resident 142's Order Summary Report (OSR), dated [DATE], the OSR did not indicate physician ordered the medical emergency treatment and Resident 142's wishes in the event of an emergency.
During a review of the facility's policy and procedure (P&P) titled, Advance Directives, revised [DATE], the P&P indicated, The resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment. Advance directives are honored in accordance with state law and facility policy. Determining Existence of Advance Directive .1. Prior to or upon admission of a resident, the social services director or designee inquires of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives. 2. The resident or representative is provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. 3. Written information about the right to accept or refuse medical or surgical treatment, and the right to formulate an advance directive is provided in a manner that is easily understood by the resident or representative.

Based on observation, interview, and record review the facility failed to ensure one of eight sampled residents, (Resident 45), when Resident 45's room was not maintained in a clean homelike environment.
Findings:
During an observation on 4/16/24 at 9:19 a.m. in Resident 45's room, Residents 45's wall and floorboards to the left of resident's bed, had multiple splatters of a brown substance.
During a concurrent observation and interview on 4/16/24 at 9:36 a.m. with Director of Nursing (DON) in Resident 45's room, DON stated, No this [Resident 45's room] is not clean or acceptable. DON stated the wall and floorboard next to Resident 45's bed does not look like it's been cleaned in a while.
During a review of the facilities policy and procedure (P&P) titled, Resident Rooms and Environment, dated 8/2020, the P&P indicated, The Facility provides residents with a safe, clean, comfortable, and homelike environment . I. Facility Staff aid to create a personalized, homelike atmosphere, paying close attention to the following: A. Cleanliness and order .

Based on observation, interview, and record review, the facility failed to prepare a pureed menu item according to the recipe instructions. This failure had the potential to result in food lacking nutritive value.
Findings:
During a concurrent observation and interview on 4/17/24 at 10:17 a.m. with [NAME] (CK) 1 in the kitchen, CK 1 poured an unknown amount of thickener (a substance to thicken pureed foods) into a pan of pureed spinach. CK 1 did not have the recipe for the pureed spinach and did not have a measuring cup to measure the thickener. CK 1 stated she knows the recipe and how much thickener is supposed to be added. CK 1 stated she does not use the measuring cup because she can eyeball it.
During a concurrent observation and interview on 4/17/24 at 10:18 a.m. with Registered Dietitian (RD) in the kitchen, CK 1 prepared a pureed spinach without measuring the thickener. RD 1 stated, she [CK 1] should be measuring it [thickening agent] out and following the recipe. That is our policy.
During a review of the facility's policy and procedure (P&P) titled, Food Preparation, [undated], the P&P indicated, Food shall be prepared by methods that conserve nutritive value, flavor, and appearance. The facility will use approved recipes, standardized to meet the client census.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure two of two sampled residents (Resident 142 and Resident 143) and/or the resident representative received a summary of the Baseline Care Plan (BCP-the minimum healthcare information necessary to properly care for each resident immediately upon their admission) within 48 hours of admission. This failure had the potential for unmet care needs for Resident 142 and Resident 143.
Findings:
During a review of Resident 143's admission Record (AR), the AR indicated Resident 143 was admitted on [DATE] with diagnosis including Cerebral Palsy (a group of disorders that affect a person's ability to move and maintain balance and posture) and unsteadiness on her feet.
During a concurrent interview and record review on 4/15/24 at 2:33 p.m. with Licensed Vocational Nurse (LVN) 1, Resident 143's BCP, dated 4/14/24 was reviewed. The BCP was not completed. The BCP was not signed, and the resident or resident representative signatures were not obtained indicating receipt of the summary of the BCP. LVN 1 stated she had not given the BCP to Resident 143 or resident representative.
During a review of Resident 142's AR, the AR indicated Resident 142 was admitted on [DATE] with diagnosis of metabolic encephalopathy (a state of brain dysfunction) and unsteadiness on feet. The AR indicated Resident 142 was Spanish speaking.
During a concurrent interview and record review on 4/15/24 at 2:38 p.m. with LVN 1, Resident 142's BCP, dated 4/6/24 was reviewed. Resident 142's BCP was not completed. LVN 1 stated the BCP was not completed and there was no signature of the resident or the resident representative indicating receipt of a written summary of the BCP.
During a review of the facility's policy and procedure (P&P) titled, Baseline Care Plan, [undated], the P&P indicated, 1. The baseline care plan will: a. Be developed within 48 hours of resident's admission. b. Include the minimum healthcare information necessary to properly care for a resident including, but not limited to: Initial goals based on admission order, physician orders, dietary orders, therapy services, social services .4. A written summary of the baseline care plan will be provided to the resident and representative in a language that the resident/representative can understand. The summary shall include, at a minimum the following: a. The initial goals of the resident b. A summary of the resident's medications and dietary instructions. c. Any services and treatments to be administered .

Based on observation, interview, and record review, the facility failed to:
1. Provide the necessary care to maintain good grooming and personal hygiene for one of eight sampled residents (Resident 4). This failure resulted Resident 4 having long and dirty fingernails.
2. Ensure one of eight sampled residents (Resident 45) was assisted with oral care. This failure resulted in Resident 45 having dental issues and/or tooth decay.
Findings:
During a concurrent observation and interview on 4/15/24 at 9:50 a.m. with Certified Nursing Assistant (CNA) 4 in Resident 4's room, Resident 4's fingernails on her left hand were long (passed the fingertips) and had blackish discoloration underneath the fingernails. CNA 4 stated nails should be cleaned every day. Sunday is the day when we do nail care for our residents.
During an interview on 4/15/24 at 10:04 a.m. with Licensed Vocational Nurse (LVN) 4, LVN 4 stated Resident 4 had long fingernails and there was dirt underneath the fingernails.
During a review of the facility's policy and procedure (P&P) titled, Fingernails/Toenails, Care of, dated 2018, the P&P indicated, The purpose of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infection. 1. Nail care includes daily cleaning and regular trimming. 2. Proper nail care can aid in the prevention of skin problems around the nail bed.
During an observation on 4/16/23, at 9:06 a.m. in Resident 45's room, Resident 45's teeth had a dark discoloration and/or buildup of plaque (a sticky film that coats teeth and contains bacteria and can damage the teeth).
During a concurrent observation and interview on 4/16/24, at 9:08 a.m. with LVN 4, in Resident 45's room, LVN 4 stated Resident 45's teeth have been like that for awhile, we (the facility) does oral care but it (plaque buildup) does not come off. LVN 4 stated the staff attempts oral care once per shift.
During a concurrent observation and interview on 4/16/24 at 9:12 a.m. with Clinical Resource Nurse (CRN) in Resident 45's room, CRN stated there was dried mucous build up and it did not appear oral care had been done today.
During a concurrent observation and interview on 4/16/24 at 9:23 a.m. with Director of Nursing (DON), in Resident 45's room, DON stated she would describe Resident 45's dental health as poor, looked like there were cavities, and there was build up of some sort like plaque.
During a review of Resident 45's Care Plan (CP), dated 2024, the CP indicated Resident 45 had a physical functioning deficit related to mobility impairment requires total care with all ADL's (activities of daily living).
During a review of Resident 45's Minimum Data Set (MDS-resident assessment tool)-Section C Cognitive Patterns, dated 3/14/2024, the MDS indicated, Resident 45 assessment was not able to be conducted. The MDS indicated Resident 45's cognitive skills for daily decision making were severely impaired.
During a review of Resident 45's MDS-Section GG-Functional Abilities and Goals, dated 3/14/2024, the MDS indicated, Resident 45's Self-Care Assessment for oral hygiene (the ability to use suitable items to clean teeth) was dependent (Helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity).
During a review of the facility policy and procedure (P&P) titled, Activities of Daily Living [ADL], Supporting, dated 3/2018, the P&P indicated, Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living [ADL]. Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene .2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. hygiene (bathing, dressing, grooming, and oral care).

Based on observation, interview, and record review, the facility failed to provide two of two sampled residents (Resident 29 and Resident 87) activity choices that met the residents likes and interests in accordance with the residents' assessment and care plan. This failure resulted in Resident 29 and Resident 87's expression of boredom and not meeting the resident's interest to improve their sense of well-being.
Findings:
During a concurrent observation and interview on 4/16/24 at 9:21 a.m. with Resident 29, in Resident 29's room, Resident 29 was sitting at the edge of the bed looking at the wall. Resident 29 stated, I get bored here, there is nothing to do. There are no magazines, no books, no newspaper for me to read. I love to read. I watch television sometimes, but that's it. I color some. That's all I do. Resident 29 did not have any books, magazines, or newspaper on her nightstand nor on the overbed table. Resident 29 stated,They took away the picture of my mom and my love. I have nothing here.
During an interview on 4/17/24 at 2:07 p.m. with Activities Director (AD), AD stated, Resident 29 likes to participate in our parties, likes to color, do crossword puzzles, and word searches. Sometimes, she joins us in our coffee socials. We do not do group activities at this time because of COVID (a serious respiratory infection), but we provide in-room visits daily. AD stated the last time she visited Resident 29 was yesterday (4/16/24 at 4:30 p.m.). AD stated she divided the residents according to the staff she has, and the staff has until the end of the shift to conduct activities with the residents. AD stated Activity Assistant (AA) 1 was assigned to assist Resident 29 with activities.
During an interview on 4/17/24 at 2:27 p.m. with AA 1, in the presence of AD, AA 1 stated she could not remember what activities she did with Resident 29. AA 1 stated she thought maybe she did sensory with lotion but could not remember the time. AA 1 stated Resident 29 wants to read books, or magazines. AA 1 stated on Tuesday morning 4/16/24 around 9:30 a.m. she was in Resident 29's room and offered her magazines and chronicle.
During a review of Resident 29's Activities Care Plan, dated 3/18/24, the care plan indicated, Focus: Resident 29 is pretty independent, participating in her favorite activities. At most she may need help with newer or more complex programs of choice. Goals: Resident 29 enjoys looking through magazines, reading; she also enjoys daily chronicle, coffee social and news, watching tv, coloring, reading, participating in parties, socializing with staff and peers, and exercising. Intervention: Check in with Resident 29 to make sure she can still do activities independently and have any supplies she needs .
During an interview on 4/16/24 at 9:43 a.m. with Resident 87, Resident 87 stated I like to play music, the guitar especially, I have been playing my whole life. Resident 87 stated, It is really sad here, have you seen some of these people, you cannot talk to them. Resident 87 stated, I would really like to play my guitars.
During an interview on 4/18/24 at 11:04 a.m. with AA 2, AA 2 stated, [Resident 87] really likes music. He used to have his guitars here and I think his family took them. (Resident 87) would play every day. AA 2 stated the facility does not have any musical instruments for residents.
During an interview on 4/18/24 at 3:12 p.m. with AD, AD stated Resident 87 had a guitar here at the facility, but his family member took it home. AD stated she thought it would be a good thing for Resident 87 to have a guitar. AA 2 stated Resident 87 likes to play the guitar and it is important to him.
During a review of Resident 87's Minimum Data Set (MDS-resident assessment tool), dated 3/5/24, the MDS indicated, [Resident 87] had a Brief Interview for Mental Status (BIMS-a 15 -point cognitive assessment; score of 8-12 means moderate impairment) Score of 9,
During a review of Resident 87's Activities-Initial Review (AIR), dated 2/23/24, the AIR did not indicate Resident 87's love for playing the guitar.
During a review of the facilities policy and procedure (P&P) titled, Activity Evaluation, dated 2/2023, the P&P indicated, In order to promote the physical, mental, and psychological well-being of residents, an activity evaluation is conducted and maintained for each resident at least quarterly and with any change of condition that could affect his/her participation in planned activities . 4. The resident's lifelong interests, spirituality, life roles, goals, strengths, needs and activity pursuit patterns and preferences are included in the evaluation.

Based on interview and record review, the facility failed to ensure Social Services followed up on the status of the hearing aids for two of two sampled residents (Resident 29 and Resident 36). This failure had the potential to result in poor communication and loss of hearing abilities.
Findings:
During an interview on 4/16/24 at 9:26 a.m. with Resident 29, Resident 29 stated, I have hearing problems. They checked my ears, but I have not heard from them about my hearing aids.
During a concurrent interview and record review on 4/17/24 at 8:35 a.m. with Social Services Director (SSD), Resident 29's Audiogram (a chart that shows the results of a hearing test), dated 1/5/24, was reviewed. The audiogram report indicated, Right and left ear had moderately severe hearing loss. Notes: The patient has hearing loss significant to qualify for hearing aids and is eligible for them under Medical (payment program). We will start the process of obtaining their hearing aids. SSD stated she had no log to trigger which residents needed follow-up. SSD stated she had not made a follow up for Resident 29's hearing aids since January 2024.
During a review of the facility's policy and procedure (P&P) titled, Hearing Impaired Resident, Care Of, dated 2/2018, the P&P indicated, 5. Staff will help residents who have lost or damaged hearing devices in obtaining services to replace the devices.
During a review of the facility's P&P titled, Hearing and Vision Services, dated 2024, the P&P indicated, 4. The social worker/social services designee is responsible for assisting residents, and their families in locating and utilizing any available resources (e.g. Medicare or Medicaid program payment, local health organizations offering items and services which are available free to the community), for the provision of the vision and hearing services the resident needs.
During a concurrent observation and interview on 4/16/24 at 10:26 a.m. with Resident 36 in Resident 36's room, Resident 36 was not wearing hearing aids. Resident 36 stated she is very hard of hearing, and she does not have hearing aids. Resident 36 stated she used to have hearing aids and they were very effective.
During a concurrent interview and record review on 4/17/24 at 2:06 p.m. with SSD, Resident 36's Pure Tone Audiogram (PTA), dated 7/19/23 was reviewed. The PTA indicated, The patient has hearing loss significant enough to qualify for hearing aids, and is eligible for them under Medi-Cal. SSD stated she should have followed up with the hearing aid company.

Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 68) received treatment for contractures (shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) in his left hand. This failure had the potential for worsening of Resident 68's contracture.
Findings:
During an observation on 4/16/24 at 10:55 a.m. in Resident 68's room, Resident 68's left hand had contractures. Resident 68 did not have a physician's ordered rolled-up washcloth in his hand.
During a concurrent interview and record review on 4/17/24 at 11: 20 a.m. with Infection Preventionist (IP), Resident 68's Orders, dated 12/29/23 were reviewed. Resident 68's Orders indicated, Cleanse Left hand Contraction with soap and water, gently pat dry and place rolled up washcloth QD [every day]. IP stated the Restorative Nursing Assistants (RNAs) put the rolled-up wash cloths in resident's hands when ordered by the doctor. IP stated Resident 68 should have his left hand cleaned and a rolled-up washcloth placed in the left hand every day.
During a concurrent observation and interview on 4/17/24 at 11:39 a.m. with IP in Resident 68's room, Resident 68 did not have a rolled-up washcloth in his left hand. IP stated Resident 68 should have a rolled-up washcloth in his left hand.
During an interview on 4/17/24 at 11:55 a.m. with RNA 1, RNA 1 stated she did not clean, pat dry and place a rolled-up washcloth in Resident 68's left hand because the treatment order was not in her IPad.
During a review of resident 68's RESTORATIVE NURSING documentation, date range 4/1/24 to 4/18/24 was reviewed. There was no documentation of RNA's treatment to left hand.
During a review of the facility's policy and procedure (P&P) titled, Restorative Nursing Services (RNS), revised 7/2017, the RNS indicated, Residents will receive restorative nursing care as needed to help promote optimal safety and independence.

Based on interview and record review, the facility failed to ensure communication and coordination between the facility and dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working) center was complete with assessments of the dialysis access site (surgically created access) on the Dialysis Communication Form for two of two sampled residents (Resident 39 and Resident 49). This failure had the potential to result in complications due to not properly assessing the dialysis site.
Findings:
During a concurrent interview and record review on 4/16/24 at 10:50 a.m. with Licensed Vocational Nurse (LVN) 2, the Nurses Dialysis Communication Record (NDCR) for Resident 39, dated 4/11/24 and 4/13/24 was reviewed. The NDCR indicated post-dialysis monitoring was blank on 4/11/24 and 4/13/24. LVN 2 stated these forms were incomplete and should be completed right away once resident was back in facility.
During a concurrent interview and record review on 4/17/24 at 3:13 p.m. with LVN 2, NDCR for Resident 49, dated 4/10/24 was reviewed. The NDCR indicated post-dialysis monitoring was blank. LVN 2 stated post dialysis monitoring should be completed right away once resident was back from dialysis.
During a review of the facility's policy and procedure (P&P) titled, Hemodialysis, dated 2023, the P&P indicated, This facility will provide the necessary care and treatment, consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences, to meet the special medical, nursing, mental, and psychosocial needs of residents receiving hemodialysis. The facility will assure that each resident receives care and services for the provision of hemodialysis consistent with professional standards of practice. This will include: The ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility.

Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 54) was assessed to determine the level of risk for bed entrapment (patient is caught, trapped, or entangled in the spaces in or about the bedrail, mattress or bed frame). This failure had the potential for adverse consequences.
Findings:
During an observation on 4/15/24 at 12:07 p.m. in Resident 54's room, Resident 54's bed had two quarter bedrails up on both sides of the bed.
During a concurrent interview and record review on 4/17/24 at 10:47 a.m. with Licensed Vocational Nurse (LVN) 1 Resident 54's assessment, dated 3/10/24 was reviewed. LVN 1 was unable to provide documentation of a bed entrapment assessment for Resident 54 and stated they did not have it.
During an interview on 4/17/24 at 10:54 a.m. with Director of Maintenance (DM), DM stated there were three beds with bed rails, 20 A, 6 B, and 27 B. DM stated he started bed safety check for the beds with bedrails this month. DM was not able to provide the bed safety check for Resident 54 prior to installation of the bedrails.
During a review of the facility's policy and procedure (P&P) titled, Proper Use of Bedrail, dated 2023, the P&P indicated, It is the policy of this facility to utilize a person-centered approach when determining the use of bedrails, 3. The resident assessment must also assess the resident's risk from using bedrails. Examples of the potential risks with the use of bedrails include: a Accidents (e.g., falls, entrapment, and other injuries sustained from attempts to climb over, around, between, or through the rails, or over the footboard. b. Barrier to residents from safely getting out of bed .4. The resident assessment should assess the resident's risk of entrapment between the mattress and bedrail or in the bed rail itself.

Based on interview and record review, the facility failed to ensure the physician evaluated and addressed weight loss for one of one resident (Resident 80). This failure had the potential for the resident to not receive proper medical care for weight loss.
Findings:
During a concurrent interview and record review on 4/16/24 at 10:20 a.m. with Licensed Vocational Nurse (LVN) 1, Resident 80's Situation, Background, Assessment, Recommendation (SBAR-a verbal or written communication tool that helps provide essential, concise information) Communication Form, dated 4/5/24, indicated Resident 80 had a weight loss of seven pounds (lbs.) in one month. Resident 80's weight on 3/4/24 was 113 lbs. and on 4/1/24 Resident 80's weight was 106 lbs. LVN 1 stated the Interdisciplinary Team (IDT- a group of professionals who help people receive the care they need) met and recommended to add House Supplement (high calorie nourishment) at breakfast. LVN 1 stated the IDT team is composed of the Director of Nursing (DON), Assistant Director of Nursing (ADON), Social Services Director (SSD), Medical Records Director (MRD) and the Registered Dietitian (RD).
During a concurrent interview and record review on 4/17/24 at 1:49 p.m. with LVN 1, Resident 80's Progress Notes, dated 4/5/24 was reviewed. The Progress Notes did not indicate the physician evaluated or addressed Resident 80's weight loss. LVN 1 stated there was no physician documentation regarding weight loss. LVN 1 stated the physician was not a member of the IDT. LVN 1 stated the physician gets notified of the incident or the condition of the resident, but he does not participate in the IDT meetings. The physician was notified of the weight loss and recommendation of the IDT.
During a review of the facility's policy and procedure (P&P) titled, Physician Services, dated 2/2021, the P&P indicated, 3. Supervising the medical care of residents includes, but not limited to: a. participating in the resident's assessment and care planning, 2. monitoring changes in resident's medical status .h. Overseeing a relevant plan of care for the resident .

Based on interview and record review, the facility failed to provide documentation of competency and skill performance for six of eight sampled employees (Certified Nursing Assistant [CNA] 5, CNA 7, Restorative Nursing Assistant [RNA] 2, Registered Nurse [RN] 1, Assistant Director of Nursing [ADON], and Infection Preventionist [IP]). This failure had the potential to result in lack of competent and skilled staff.
Findings:
During a concurrent interview and record review on 4/16/24 at 10:27 a.m. with Director of Staff Development (DSD), no competency evaluations or skills performance checklists were found in CNA 5, CNA 7, or RNA 2's employee personnel records (EPRs). DSD stated CNAs are supposed to shadow another CNA during orientation. DSD stated she does not have any competency assessments for CNAs.
During a concurrent interview and record review on 4/16/24 at 10:45 a.m. with DSD, RN 1, ADON, and IP's EPRs were reviewed. There were no competency evaluations or skills performance checklists found in the EPRs. DSD stated the RNs and LVNs would be reviewed by the Director of Nursing and then filed in the EPRs.
During a concurrent interview and record review with Administrator on 4/16/24 at 2:08 p.m. the facility's forms titled, Nursing Assistant Orientation & Competency Evaluation Nursing Skills Performance Satisfactory Completion (NAC) and Licensed Nurse Competency (LNC) were reviewed. The NAC indicated a check off list for various skills including, but not limited to, bed bath, blood pressure, communication with the resident, special feeding problems, handwashing, shaving, showering, oral hygiene, incontinent skin care, mechanical lift, and use of wheelchairs and walkers. The LNC indicated a check off list of competency assessments for general policy and procedures, infection control, behavioral health, basic nursing skills, restorative nursing skills, documentation, identification of changes in condition, and in-house communication. Administrator stated the facility was supposed to do competency checklists for everyone upon hire and annually.
During a review of the facility's Policy and Procedure (P&P) titled, On-the-Job Training, dated 2001, the P&P indicated, On-the-job training programs will be conducted when necessary to assist employees in performing their assigned tasks. 1. On-the-job training is provided to train each employee in his/her respective job assignments and our methods of performing such tasks. 2. Department directors will be responsible for on-the-job training to assure that our established training schedules are followed. (Note: Non-supervisory personnel may be assigned as on-the-job trainers.) 3. On-the-job training begins on the first day of employment and is completed when the department director is satisfied that the employee can perform his/her assigned duties, within the time frame allotted for each particular function, without further supervision. 6. All training programs and classes attended by an employee shall be entered on his/her Employee Training Attendance Record. 7. Training records will be filed in the employee's personnel file or may be maintained by the department supervisor.

4. During a concurrent observation and interview on 4/16/24 at 9:11 a.m. with Infection Preventionist (IP), in Central Supply Room (CSR-area where facility supplies are stored), one cabinet was designated for treatment supplies. The treatment supply cabinet was open and had several medications inside the cabinet. The following medications were noted:
Six boxes of triple antibiotic ointments (medication used to reduce the risk of infections following minor skin injuries).
One bottle Hydrogen Peroxide (antimicrobial substance used on the skin to prevent infection of minor cuts, scrapes, and burns).
Two boxes of Hydrocortisone Cream 1 % (topical medication used to treat redness, swelling, itching, and discomfort of various skin conditions).
IP stated the cabinet had medications and was not locked. IP stated anyone could access the room. IP stated residents toiletries were stored in this room, resident food refrigerator was kept in this room, and medication carts were stored in this room. IP stated the treatment cabinet should be locked, but it was not locked today.
During a review of the facility's policy and procedure (P&P) titled, Medication Labeling and Storage, dated 2023, the P&P indicated, The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys. 7. Controlled substances (listed as Schedule 11-V of the Comprehensive Drug Abuse Prevention and Control Act of 1976) and other drugs subject to abuse are separately locked in permanently affixed compartments, except when using single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.
Based on observation, interview, and record review, the facility failed to:
1. Ensure controlled substances (highly abused drugs) were stored in a locked cabinet. This failure had the potential for controlled substances to be diverted.
2. Ensure expired medications were not stored with active stock of medications. This failure had the potential to expose residents to expired medicaitons with unknown potency and efficacy.
3. Ensure destruction of medications were done in accordance with the facility policy. This failure had the potential for employees to divert discarded medications.
4. Ensure the treatment cabinet with medications in Central Supply Room was locked. This failure had the potential for medications to be accessed by unauthorized users.
Findings:
1. During a concurrent observation and interview on 4/17/24 at 10:36 a.m. with Licensed Vocational Nurse (LVN) 3 in Medication Room, the Narcotic Emergency Kit (narcotic scheduled II, III, IV and V which are highly abused drugs) was in cabinet drawer that was not locked. LVN 3 stated the drawer should be locked.
During an interview on 4/17/24 at 11:06 a.m. with DON, DON stated medications containing controlled substances should be locked in the drawer.
2. During a concurrent interview and record review on 4/17/24 at 10:37 a.m. with LVN 3, a Vancomycin (medication is used to treat bacterial infections) intravenous (IV-within the vein) infusion [method of delivering medication into the bloodstream) bag was in the medication refrigerator inside the medication room. The label on the bag indicated, Refrigerated Discard After: 04/15/24 @ 1500. The label indicated the medication was for Resident 244. LVN 3 stated this antibiotic should have been discarded on 4/15/24 and not stored with the active medications.
3. During a concurrent interview and record review on 4/17/24 at 11:04 a.m. with Director of Nursing (DON), Medication Disposition Record/Pass Log (MDR), was reviewed. The MDR indicated, there was no second signature witnessing the destruction of medications. The Witnessed by column on the log form was blank. DON stated a second witness was required for the destruction of medication and the logs should contain witness signatures for all drugs being destroyed.
During an interview on 4/17/24 at 11:45 a.m. with the DON, DON stated the last time the medication destruction bin was picked up for disposal was 3/31/24, so no medications have been destroyed since then. DON stated the MDR contained no reason for destruction and no witness signature.
During a review of the facility's policy and procedure (P&P) titled, Discarding and Destroying Medications, dated 2022, the P&P indicated, Medications that cannot be returned to the dispensing pharmacy (e.g., non-unit dose medications, medications refused by the resident, and/or medications left by residents upon discharge) are disposed of in accordance with federal, state and local regulations governing management of non-hazardous pharmaceuticals, hazardous waste and controlled substances. 7. For unused, non-hazardous controlled substances that are not disposed of by an authorized collector, the EPA recommends destruction and disposal of the substance with other solid waste following the steps below: a. Take the medication out of the original containers. b. Mix medication, either liquid or solid, with an undesirable substance. Undesirable substances include sand, coffee grounds, kitty litter, or other absorbent materials. Place the waste mixture in a sealable bag, empty can, or other container to prevent leakage. 10. The medication disposition record contains, as a minimum, the following information: a. The resident's name. b. The name and strength of the medication. c. The prescription number (if any). d. The name of the dispensing pharmacy. e. Date medication destroyed. f. The quantity destroyed. g. Method of destruction. H. Reason for destruction. i. Signature of witnesses.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure Social Services followed up dental services for three of three sampled residents (Resident 29, Resident 36 and Resident 41). This failure had the potential for unplanned weight loss.
Findings:
During an interview on 4/16/24 at 9:26 a.m. with Resident 29, Resident 29 stated she had upper dentures and lower partials. Resident 29 stated, I need the upper dentures fixed because they fall off when I eat and when I speak. They are old. Really bad.
During a concurrent interview and record review on 4/17/24 at 9:01 a.m. with Social Services Director (SSD), Resident 29's Dental Notes (DN), dated 8/18/23, 12/20/23, and 3/26/24 were reviewed. The DN, dated 8/18/23 indicated, Denture evaluation done. Patient is requesting new full upper denture (FUD). Is worn down. FUD is old and dirty. MO (medical) submitted. The DN, dated 12/20/23 indicated, Full mouth x-rays (FMX). The 3/26/24 DN indicated,MO request submitted. SSD stated she had not followed up on the status of the dentures for Resident 29.
During an interview on 4/16/24 at 8:59 a.m. with Resident 41, Resident 41 stated he had not seen a dentist in two years.
During an interview on 4/17/24 at 1:42 p.m. with SSD, SSD stated Resident 41 had not been seen by a dentist. SSD stated Resident 41 should have had a dental evaluation on admission and every six months for cleaning.
During a review of Resident 41's admission Record (AR), the AR indicated Resident 41 was admitted on [DATE].
During an interview on 4/16/24 at 10:32 a.m. with Resident 36, Resident 36 stated she had not seen a dentist in a long time.
During an interview on 4/17/23 at 2:13 p.m. with SSD, SSD stated Resident 36 has not been seen by a dentist. SSD stated Resident 36 should have had a dental evaluation on admission and every six months for cleaning.
During a review of Resident 36's AR, the AR indicated Resident 36 was admitted on [DATE].
During a review of the facility's policy and procedure (P&P) titled, Dental Examination Assessment, [undated], the P&P indicated, Each resident shall undergo a dental assessment prior to or within ninety (90) days of admission.
During a review of the facility's policy and procedure (P&P) titled, Social Services, dated 9/2021, the P&P indicated, 2. Medically related social services are provided to maintain or improve each resident's ability to control every day physical needs (e.g., appropriate adaptive equipment for eating, ambulation, etc.) .

Based on observation, interview, and record review the facility failed to:
1. Ensure opened food items were labeled with an expiration date.
2. Ensure the ice machine expired water filter was replaced per manufacture's guidelines.
These failures had the potential to result in decreased palatability (tastiness) and the potential for spread of foodborne illnesses.
Findings:
1. During a concurrent observation and interview on 4/16/24 at 8:51 a.m. with Interim Dietary Supervisor (IDS), in the dry food storage area, an opened bag of egg noodles was not labeled with the opened date. IDS stated this is an opened bag of egg noodles and it is not labeled with an opened date. IDS stated it should have an opened date.
During a concurrent observation and interview on 4/17/24 at 9:59 a.m. with Registered Dietitian (RD), in the kitchen, the following spices and seasoning containers were opened with no opened and/or no expiration dates:
Onion powder-no opened date, no expiration date
Lemon pepper-no expiration date
Ground cumin-no expiration date
Ground nutmeg-no expiration date
Light chili powder-no expiration date
RD stated the staff are supposed to label the container when they open it and with the expiration date on it. RD stated, That is our policy.
During a review of the facility's policy and procedure (P&P) titled, Storage of Food and Supplies, dated 2023, the P&P indicated, Food and supplies will be stored properly and in a safe manner . 8. Labels should be visible . All food will be dated- month, day, year.
2. During a concurrent observation and interview on 4/17/24 at 8:27 a.m. with Director of Maintenance (DM), the ice machine external water filtration system had a label indicating it was last changed on 7/28/23. DM stated we have a new filter on order, but this one is expired because its supposed to be changed every 6 months. DM stated he is aware the filter is expired and needs to be changed as it was last changed on 7/28/23.
During a review of the 3M Water Filtration Products Instructions for use (IFU), the IFU indicated, The disposable filter cartridge in your system requires regular maintenance to ensure optimal performance . 1. Frequency of Replacement: The filter cartridge should be replaced every six months or earlier if you notice a reduction in water flow to the dispenser or icemaker.
During a review of the Ice Machine Manufacturer Installation Manual (IMM), the IMM indicated, Water Supply: Local water conditions may require treatment of the water to inhibit scale formation, filter sediment, and remove chlorine odor and taste. Water Inlet Lines: Follow these guidelines to install water inlet lines: If you are installing a water filter system, refer to the installation instructions supplied with the filter system for ice making water inlet connections.
During a review of the facility's policy and procedure (P&P) titled, Ice Machine Cleaning Procedures, [undated], Information about the operation, cleaning and care of the ice machine can be obtained from the owner's manual, the manufacturer's and/or in the directional panel on the inside of the ice machine.

Based on observation, interview, and record review, the facility failed to ensure the Governing Body:
1. Provided oversight to their Infection Prevention and Control Program (IPCP) and the Infection Preventionist (IP-individual responsible for the facility's IPCP and help prevent the transmission of communicable diseases and infections). This failure resulted in the removal of the personal belongings, memorabilia, and clothing for five of five sampled residents (Resident 29, Resident 35, Resident 54, Resident 72, and Resident 80), which could potentially have a negative effect on the residents' well-being.
2. Established water management program as part of the Infection Control Program under the leadership of the Infection Preventionist. This failure had the potential for transmission of water-borne infections.
3. Developed and implemented Quality Assurance and Performance Improvement (QAPI) policies and procedures. This failure had the potential for residents and staff to be placed at risk for harm when the facility did not have QAPI framework to achieve quality care and services for 92 of 92 residents residing in the facility.
Findings:
1. During a concurrent observation and interview on 4/18/24 at 7:10 a.m. with Housekeeping and Laundry Manager (HLM), in the dirty section of the laundry room, there were several plastic bags on the floor piled on top of each other. The plastic bags had grayish colored debris. HLM stated those bags contained the personal belongings of residents in isolation, such as luggage, picture frames, pictures and other items. The items were removed from the residents' rooms due to scabies outbreak. Beside the residents' personal belongings were janitorial supplies, brooms, dustpans, a trash can, and two barrels with clean mops and rugs. HLM stated we had no space or storage area to keep the residents' personal belongings. HLM stated they had not been instructed to return the residents' personal belongings.
During a concurrent observation and interview on 4/18/24 at 9:01 a.m. with IP in the laundry room, IP noted the residents' personal belongings, clothing, and memorabilia were in plastic bags on the floor piled on top of each other and the plastic bags had grayish debris. IP stated, The scabies outbreak started on 1/11/24. Since then, I have directed to deep clean the room, take the curtains down, take all the residents' clothing out, all the personal belongings, seal them, and take them to Laundry. IP stated it was just for the residents with scabies. IP stated it was not a physician's order, but was my decision to contain infection.
During an interview on 4/18/24 at 3:38 p.m. with Administrator, Administrator stated she was not aware residents' clothing and personal belongings were taken out of the residents' rooms. Administrator stated sometimes we have to think of our actions and how our actions could negatively affect the residents. Administrator stated she had not been in the Laundry and had not seen where and how the residents' personal belongings and clothing were stored in the Laundry.
During an interview on 4/18/24 at 3:40 p.m. with Director of Nursing (DON) DON was also not aware the residents' personal belongings and clothing were removed from the rooms and stored in the Laundry.
During a review of the Centers for Disease Control and Prevention Guidelines, titled Parasites-Scabies Prevention & Control, dated 10/31/18, the Guidelines indicated, Scabies is prevented by avoiding direct skin-to-skin contact with infested person or with items such as clothing or bedding used by an infested person. Items that cannot be dry-cleaned or laundered can be disinfested by storing in a closed plastic bag for several days or weeks. Scabies usually do not survive more than two-three days away from human skin. Environmental disinfestation using pesticide sprays or fogs generally is unnecessary and is discouraged. Environmental disinfestation is neither necessary nor warranted. Routine cleaning and vacuuming of the room should be done if and when the patient with non-crusted scabies leaves the facility or moves to a new room.
2. During an interview on 4/18/24 at 12:20 p.m. with Administrator, Administrator stated, We do not have Water Management Policies and Procedure. I just received the Risk Management Plan for Legionella Control from the Environment Consultant. We have not put anything in place.
During a review of the facility's policy and procedure (P&P) titled, Infection Prevention and Control, dated 2023, the P&P indicated, 17. Water Management: a. A water management program has been established as part of the overall infection prevention and control program. b. Control measures and testing protocols are in place to address potential hazards associated with the facility's water system. c. Maintenance Director serves as the leader of the water management program.
3. During a concurrent interview and record review on 4/18/24 at 3:38 p.m. with Administrator and DON, the facility's QAPI Program policies and procedures were reviewed. Administrator provided a booklet titled, QAPI Guidance, Performance Improvement Projects, dated 2022. The document provided was not facility-specific and only served as guidance for how to develop and implement a QAPI Program. Administrator stated the booklet was what the facility has for their QAPI.
During a review of the document titled, QAPI Guidance/Performance Improvement Projects, dated 2022, the document indicated, The facility must set priorities for its performance improvement activities that focus on high risk, high volume, and problem prone areas. The Process Improvement Projects (PIP) must consider the incidence, prevalence, and severity of problems in those areas as how they affect health outcomes.

Based on interview and record review, the facility failed to provide the Binding Arbitration Agreement in simple, understandable language or language common to the area other than English. This failure had the potential for residents to not fully understand the terms of the agreement and the nature or the possible consequences as a result of the agreement.
Findings:
During an interview on 4/17/24 at 5:49 p.m. with Business Office Manager (BOM) in the presence of the Administrator, BOM stated most of the arbitration discussion occurs on admission. BOM stated the agreement for entering a binding arbitration was part of the admission packet and, she was obligated to ask the resident or the resident representative. BOM stated she explained to the best of her ability and her knowledge what the binding arbitration meant and what it entailed, or she mailed the Binding Arbitration Agreement (BAA) to the family or resident representative. BOM stated, The facility does not have a language-assistance service. That is something I need to discuss with Corporate or the Administrator. BOM stated the facility did not have the agreement form in any other language that the resident or family could understand, except in English. BOM stated she could not explain every paragraph written in the agreement form. BOM stated the facility did not have policies and procedures written for Entering into Binding Arbitration Agreement.
Facility policy and procedure on Entering into Binding Arbitration Agreement was requested; none was provided.
During a review of the Center's for Medicare and Medicaid Services (CMS) recommendation titled, Binding Arbitration Agreement, dated 6/5/17, the recommendation indicated the following:
All agreements for binding arbitration must be in plain language.
If signing the agreement for binding arbitration is a condition of admission into the facility, the language of the agreement must be in plain writing and in the admissions contract.
The agreement must be explained to the resident and his or her representative in a form and manner they understand, including that it must be in a language they understand.
The resident must acknowledge that he or she understands the agreement.

Based on interview and record review, the facility failed to maintain an effective Quality Assurance and Performance Improvement (QAPI-a data driven and proactive approach to quality improvement) Program as evidenced by:
1. Four members of the nursing staff (Licensed Vocational Nurses [LVN] 6, LVN 7, LVN 8, and Staffing Coordinator [SC]) were not familiar with QAPI and the facility's quality improvement projects.
2. The fall interventions had not been fully monitored and evaluated, data collected, analyzed, tracked, and trended, and outcome of the process had not been fully established.
3. The facility did not have performance indicators to monitor quality of care and services in high risk and problem prone areas like Infection Control and Laundry.
These failures had the potential for residents and staff to be placed at risk for harm when the facility did not have a QAPI framework to achieve quality care and services for 92 of 92 residents residing in the facility.
Findings:
1. During an interview on 4/18/24 at 3:25 p.m. with LVN 6, LVN 6 stated, I don't know when asked what QAPI meant. LVN 6 stated she was not aware of what process improvement projects the facility was working on.
During an interview on 4/18/24 at 3:28 p.m. with LVN 7, LVN 7 stated, I don't know when asked about QAPI. LVN 7 stated she was not aware of what process improvement projects the facility was currently working on.
During an interview on 4/18/24 at 3:30 p.m. with LVN 8, LVN 8 stated, I don't know, when asked about QAPI. LVN 8 stated she was not aware of the current process improvement projects the facility was working on.
During an interview on 4/18/24 at 3:35 p.m. with SC, SC stated I don't know, when asked about QAPI. SC was unable to speak to the current QAPI projects the facility was working on.
During an interview on 4/18/24 at 3:40 p.m. with Director of Nursing (DON), DON stated she could not recall if there was a QAPI Training for the staff.
2. During a concurrent interview and record review on 4/18/24 at 4:15 p.m. with DON, DON stated the facility had been working on decreasing the number of fall incidences. Currently, the facility had 50 falls from 1/2024 to 4/2024. DON stated their goal was to decrease falls by 10 falls per month. DON stated the following were the interventions implemented:
a. Director of Staff Development (DSD) to in-service the staff on the 5 Ps: potty, pain, position, personal property within reach, and proper footwear.
b. Purposeful rounding as needed.
c. Answering call lights in a timely manner.
d. Paying attention to our patients in the hallways, such a paying attention to the residents' footwear. Are the residents wearing non-skid socks?
d. Implemented 1:1 supervision for residents.
f. Certified Nursing Assistants Training on Falls.
DON was unable to provide the data collected, analyzed, tracked, and trended, to identify any improvements based upon the interventions put in place.
3. During a concurrent interview and record review on 4/18/24 at 4:30 p.m. with Administrator and DON, Administrator and DON could not provide any performance indicators to monitor infection control, environmental improvement, and quality of service in Laundry. Administrator stated she had not been in the Laundry and had not seen the condition in Laundry. Administrator stated she was not aware residents' clothing and personal belongings had been taken away from the residents. Administrator stated that could affect the residents' home environment and their well-being when they don't get their clothes and personal belongings back.
During a review of the document titled, QAPI Guidance/Performance Improvement Projects, dated 2022, the document indicated, The facility must set priorities for its performance improvement activities that focus on high risk, high volume, and problem prone areas. The Process Improvement Projects (PIP) must consider the incidence, prevalence, and severity of problems in those areas as how they affect health outcomes.

Based on observation, interview, and record review, the facility failed to:
1. Follow infection prevention and control practices in accordance with Centers for Disease Control and Prevention (CDC, national health organization) guidelines for 92 of 92 residents residing in the facility.
2. Ensure surveillance for infection were properly conducted, data collected, analyzed, track and trended for 92 of 92 residents residing in the facility.
3. Develop and implement water management policies and procedures to assist the facility in the prevention of Legionella (waterborne bacteria that cause serious lung disease) and /or other opportunistic waterborne pathogens.
These failures had the potential to transmit infectious diseases.
Findings:
1 a. During a concurrent observation and interview on 4/15/24 at 11:13 a.m. with Certified Nursing Assistant (CNA) 1, in Hallway 1, Resident 72's door had a Contact Precaution (intended to prevent transmission of infectious agents through direct or indirect contact with contaminated objects) sign posted outside the door. CNA 1 stated Resident 72 has scabies all over her body.
During a concurrent observation and interview on 4/15/24 at 2:21 p.m. in Hallway 1, Resident 72 was pacing the hallway and asking assistance to take her to her husband. CNA 2 redirected Resident 72 back to her room while holding hands with Resident 72. CNA 2 did not perform hand hygiene after CNA 2 had taken Resident 72 back to her room.
During an interview on 4/15/24 at 2:25 p.m. with CNA 2, in Hallway 1, CNA 2 stated she knew Resident 2 was on contact precaution but did not know any other way to redirect Resident 72 but to walk Resident 72 back to her room holding Resident 72's hands.
During an interview on 4/18/24 at 2:30 p.m. with Infection Preventionist (IP), IP stated she should have instructed the CNAs not to hold hands with Resident 72 but to redirect Resident 72 guiding her from the back.
During a review of the Centers for Disease Control and Prevention (CDC) Guidelines titled, Parasite-Scabies Control, dated 10/31/18, the Guidelines indicated, Scabies is prevented by avoiding direct skin-to-skin contact with an infested person or with items such as clothing or bedding used by an infested person. Bedding and clothing worn or used next to the skin anytime during the 3 days before treatment should be machine washed and dried using the hot water and hot dryer cycles or be dry-cleaned. Items that cannot be dry-cleaned or laundered can be disinfested by storing in a closed plastic bag for several days to a week.
During a review of the facility's P&P titled, Handwashing/Hand Hygiene, dated 10/2023, the P&P indicated, All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors . Indications for Hand Hygiene: d. after touching a resident.
1 b. During a concurrent observation and interview on 4/16/24 at 8:55 a.m. with Director of Nursing (DON) and Licensed Vocational Nurse (LVN) 5, in Central Supply Room (CSR), the room was filled with carts and boxes. LVN 5 stated this is where the night nurses wash and disinfect used incentive spirometer (a device that measures the volume of the air inhaled into the lungs during inspiration). DON stated CSR is considered a clean room.
During a concurrent observation and interview on 4/16/24 at 9:06 a.m. with LVN 4 in CSR, LVN 4 wheeled the medication cart inside. LVN 4 stated CSR was considered a clean room, but we use it to store the medication carts. LVN 4 stated he only wiped down the top of the medication cart with the purple top disinfectant. LVN 4 stated he did not disinfect the cart.
During an interview on 4/16/24 at 9:06 a.m. with IP, IP stated, I would not consider the room a clean room. The med carts are not disinfected when stored
in the room.''
1 c. During a concurrent observation and interview on 4/18/24 at 7:05 a.m. with Housekeeping and Laundry Manager (HLM), outside the building near the laundry area, there was a large regular trash bin overflowing with trash, a chair among the trash bags, eight clear plastic bags filled with trash, and three empty brown boxes on the ground. HLM stated the trash was usually picked up around 5 a.m., but did not get picked up today.
1 d. During a concurrent observation and interview on 4/18/24 at 7:20 a.m. with HLM, in the dirty area of the laundry room, a large yellow water tank to flush eyes, was on top of a two-tiered rolling cart. HLM stated Maintenance checks the water tank, but she had no recollection when it was last checked.
During an interview on 4/18/24 at 8:07 a.m. with Director of Maintenance (DM), DM stated yes, the portable water tank eye wash is what the staff must use in case of an emergency. DM stated the water tank is filled up to 15 gallons of water. The eye wash station is checked once a month. DM stated, I do not have a log for the eye wash station check.
During a review of the article OSHA InfoSheet titled, Health Effects from Contaminated Water in Eyewash Stations, dated 7/2015, the article indicated,
Water found in improperly maintained eyewash stations is more likely to contain organisms (e.g., Acanthamoeba, Pseudomonas, Legionella) that thrive in stagnant or untreated water and are known to cause infections. When a worker uses an eyewash station that is not maintained, organisms in the water may come into contact with the eye, skin, or may be inhaled .Maintain equipment in accordance with industry standard (e.g., American National Standards Institute (ANSI) standard Z358,1-2014. The ANSI standard includes information that plumbed systems need to be activated once a week for at least 15 minutes to reduce microbial contamination.
1 e. During a concurrent observation and interview on 4/18/24 at 7:24 a.m. in the clean area of the laundry room, Laundry Aide (LA) was folding linens and stacking the folded linen in a cart that was not labeled clean cart. In the area where she was folding linens were several plastic bags on the floor filled with clothes piled one on top of the other. The plastic bags were unlabeled. LA stated in the bags were residents' clean clothes, socks, and shoes. LA stated, We do not have a place to store them.
During a review of the facility's P&P titled, Departmental (Environmental Services)-Laundry and Linen, dated 1/2014, the P&P indicated, Standard Precaution: 1. Separate soiled and clean linens at all times .7. Clean linen will remain hygienically clean (free of pathogens insufficient numbers to cause human illness) through measures designed to protect it from environmental contamination, such as covering clean linen carts .9. Reprocess any linen that that is not visibly clean upon completion of the cycle or any linen that falls onto the floor.
1 f. During a concurrent observation and interview on 4/18/24 at 7:57 a.m. with CNA 3, outside in the laundry's walkway, there were three rolling clothing racks. The first clothing rack had three residents' clothes on hangers. The second rolling clothing rack was filled with resident clothes on hangers and folded clothes in the bottom. The third rolling clothing rack also was filled with resident clothes on hangers and folded clothes on the bottom. It was noted the blue plastic cover was torn in several places, the edges were ripped, and the plastic was covered with grayish debris. The third rolling clothing rack's plastic cover was also torn and ripped in many places.
During an interview on 4/18/24 at 8:10 a.m. with IP, IP stated she was in the Laundry on Monday (4/15/24), but only moved some stuff for the eye wash station. IP stated she did not focus on the other areas of the laundry room. IP stated, I did not pay attention to the residents clothing and the condition of the laundry area.
During an interview on 4/18/24 at 8:20 a.m. with Administrator, Administrator stated she had not visited Laundry and had not seen the area. Administrator stated she was not aware of the poor condition of the laundry room. Administrator directed HLM to replace the torn plastic covers and stated, Those racks could not be taken inside the building.
During a review of the facility's P&P titled, Infection Prevention and Control Program, dated 2023, the P&P indicated, 12. Linens: d. Linens shall be stored on all resident care units on covered carts, shelves, in bins, drawers, or linen closet.
1 g. During a concurrent observation and interview on 4/18/24 at 8:23 a.m. with HLM in the main Central Supply Room next to the Laundry, there were boxes on the floor: at least 20 boxes of isolation gowns stacked one on top of each other, two boxes of briefs, two boxes of mattresses, and one isolation cart. HLM stated the supplies should not be on the floor.
2. During an interview on 4/18/24 at 12:13 p.m. with IP, IP stated the surveillance activities for infection conducted were on donning (put on) and doffing (take off) of Personal Protective Equipment (PPE- refers to gowns, gloves, masks, face shields/goggles used to protect the individual from infection or injury), cleaning of shower rooms, and taking the barrels out. IP stated she has not conducted any surveillance on hand hygiene.
During a concurrent interview and record review on 4/18/24 at 2:07 p.m. with IP, the surveillance activities for infection on donning and doffing of PPE, dated 4/5/24, 4/10/24, and 4/17/24 were reviewed. The PPE adherence monitoring contact precaution indicated, On 4/5/24, adherence rate was 25%, on 4/10/24 adherence rate was 25 %, and on 4/17/24 adherence rate was 50%. IP stated she had not conducted any other surveillance other than donning and doffing of PPE. IP stated she found out this month she had to do surveillance activities for infection and those were the only times she did surveillance. IP was unable to provide documentation of the analysis of the data collected, tracking and trending, and actions undertaken when non-compliance were observed.
During a review of the facility's P&P titled, Surveillance for Infection, dated 9/2017, the P&P indicated, Gathering Surveillance Data: The Infection Preventionist or designated infection control personnel is responsible for gathering and interpreting surveillance data . Interpreting Surveillance Data: 1. Analyze the data to identify trends . b. Consider how increases or decreases might relate to recent process changes, events or activities in the facility. Trends should be monitored . Surveillance data will be provided to the Infection Control Committee regularly. The Infection Control Committee will determine how important surveillance data will be communicated to the physicians and other providers, Administrator, nursing units .
During a review of the facility's P&P titled, Infection Prevention and Control Program, dated 2023, the P&P indicated, 3. Surveillance: b. The Infection Preventionist serves as the leader in surveillance activities, maintains documentation of incidents, findings, and any corrective actions made by the facility and reports surveillance findings to the facility's Quality Assessment and Assurance Committee.
3. During a concurrent interview and record review on 4/18/24 at 10:32 a.m. with Director of Maintenance (DM), DM stated the facility has no cases of Legionnaires Disease (a serious type of pneumonia [lung infection] caused by Legionella bacteria from contaminated water). DM stated he did not have any assessment of the facility's water sources and could not provide records of water testing done. DM stated, We have not tested the water, not even prior to me joining the facility. As far as I know water testing has not been done for the past three months that I have been here and the previous years.
During an interview on 4/18/24 at 12:20 p.m. with Administrator, Administrator stated, We do not have Water Management Policies and Procedure. I just received the Risk Management Plan for Legionella Control from the Environment Consultant. We have not put anything in place.
During a review of the facility's policy and procedure (P&P) titled, Infection Prevention and Control, dated 2023, the P&P indicated, 17. Water Management:
a. A water management program has been established as part of the overall infection prevention and control program. b. Control measures and testing protocols are in place to address potential hazards associated with the facility's water system. c. Maintenance Director serves as the leader of the water management program.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain and implement an effective antibiotic (fight bacterial infections) stewardship (coordinated effort to measure and improve how antibiotics are prescribed by clinicians and used by patients) program for one of one sampled resident (Resident 4). This failure had the potential to place residents at risk for harm caused by unnecessary use of antibiotics.
Findings:
During an interview on 4/18/24 at 11:05 a.m. with Infection Preventionist (IP), IP stated Resident 4 was sent to the hospital for evaluation of altered mental status and was diagnosed with sepsis (presence of harmful microorganisms in the blood) related to urinary tract infection (UTI- bacteria invade and grow in the urinary tract [the kidneys, ureters, bladder, and urethra]). IP stated Resident 4 was readmitted to the facility on [DATE] with a Multidrug Resistant Organism (MDRO-a germ that is resistant to many antibiotics) and was placed on Contact Precaution (prevent transmission of infectious agents) for Extended Spectrum Beta-Lactamase (ESBL-enzyme found in some strains of bacteria that makes the germ harder to treat with antibiotics) in the urine.
During a concurrent interview and record review on 4/18/24 at 11:15 a.m. with IP, Resident 4's electronic medical record was reviewed and IP was unable to locate urinalysis and urine culture results. IP stated a urine culture was obtained on 3/29/24, but IP was not able to find the results.
During a concurrent interview and record review on 4/18/24 at 11:25 a.m. with IP, Resident 4's Medication Administration Record (MAR) dated 3/2024 and 4/2024 were reviewed. The MAR indicated, Keflex (medication to treat infection) 500 mg (milligram) one tablet every 12 hours for UTI was administered from 3/30/24 to 4/5/24. IP stated she found out Resident 4 had ESBL prior to Resident 4 returning to the facility. IP stated Resident 4 was no longer on Contact Precaution for ESBL.
During a concurrent interview and record review on 4/18/24 at 11:35 a.m. with IP, Resident 4's Physician Order (PO), dated 4/2024, were reviewed. The PO did not indicate discontinuation of the contact precaution. IP stated she spoke with the physician and a telephone order was given to remove Resident 4 from isolation. IP stated she did not write the telephone order to discontinue Contact Precaution for Resident 4.
During a concurrent interview and record review on 4/18/24 at 11:40 a.m. with IP, Resident 4's Physician's Progress Notes were reviewed electronically. IP was not able to find documentation of the physician's progress notes regarding Resident 4's infection.
During an interview on 4/18/24 at 11:45 a.m. with IP, IP stated the Antibiotic Stewardship Committee membership is comprised of the Infection Preventionist, Director of Nursing, the Assistant Director of Nursing, Medical Records Director, and Social Services Director. The committee meets once a week. IP was unable to provide meeting minutes for the Antibiotic Stewardship Program. IP stated the documentation is integrated in the Interdisciplinary Team Notes (IDT- a group of health care professionals with various areas of expertise who work together toward the goals of their patients). IP stated, I did not know the pharmacist needs to be involved. No, pharmacist is not part of the Antibiotic Stewardship Committee.
During a review of the facility's policy and procedure (P&P) titled, Antibiotic Stewardship-Review and Surveillance of Antibiotic Use and Outcomes, dated 12/2016, the P&P indicated, 2. The IP or designee, will review antibiotic utilization as part of the antibiotic stewardship program and identify specific situations that are not consistent with the appropriate use of antibiotics.
During a review of the facility's P&P titled, Antibiotic Stewardship-Orders for Antibiotics, dated 12/2016, the P&P indicated,3. Appropriate indications for use of antibiotics include: a. Criteria met for clinical definition of active infection or suspected sepsis 2. Pathogen susceptibility, based on culture and sensitivity to antimicrobial (or therapy begun while culture is pending) .6. When antibiotics are prescribed over the phone, the primary care practitioner will assess the resident within 72 hours of the telephone order.
During a review of the facility's P&P titled, Infection Prevention and Control Program, dated 2023, the P&P indicated,6. Antibiotic Stewardship: d. The Medical Director, consultant pharmacist, and laboratory manager will serve as resources for the antibiotic stewardship program.
During a review of the facility's P&P titled, Consultant Pharmacist Antibiotic Stewardship Duties, dated 2020, the P&P indicated, The consultant pharmacist can participate in the following duties at the request of facility leadership: Participate in the Antibiotic Stewardship subcommittee that sets the standards for the antibiotic prescribing practices .

Based on interview and record review the facility failed to:
1. Administer the pneumococcal vaccine for one of three sampled residents (Resident 80) after consent was obtained.
2. Obtain vaccine refusal consent forms for one of three sampled residents (Resident 72).
These failures had the potential to spread infectious diseases
Findings:
1. During a concurrent interview and record review on 4/18/24 at 2:02 p.m. with Director of Nursing (DON), Resident 80's Immunization Consent or Declination (IC), dated 1/2/24 and Electronic Health Record (EHR) was reviewed. The IC indicated on 1/2/24 Resident 80's responsible party signed consent for Resident 80 to receive the Pneumococcal (PPSV23) and Pneumococcal (PCV12) vaccines (at admission or at a later date if clinically indicated). Resident 80's EHR indicated no Pneumococcal vaccine had been administered. DON stated Resident 80's consent for the Pneumonia vaccine was signed by the resident representative on 1/2/24, but the vaccine was not administered. DON stated, It [pneumococcal vaccine] should have been given if she [resident representative] signed the consent. DON stated I am not seeing any documentation for a refusal either.
2. During a concurrent interview and record review on 4/18/24 at 2:08 p.m. with DON, Resident 72's EHR was reviewed. DON stated there is no refusal form for Resident 72's influenza and pneumococcal vaccination status. DON stated, Refusals need to be documented on the immunization declination form.
During a review of the facility's policy and procedure (P&P) titled, Pneumococcal Vaccine, dated 10/2023, the P&P indicated, All residents are offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. 1. Prior to or upon admission, residents are assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, are offered the vaccine series within thirty (30) days of admission to the facility unless medically contraindicated or the resident had completed the current recommended vaccine series . 5. Residents/representatives have the right to refuse vaccination. If refused, appropriate information is documented in the resident's medical record indicating the date of the refusal of the pneumococcal vaccination.
During a review of the facility's policy and procedure (P&P) titled, Influenza Vaccine, dated 3/2022, the P&P indicated, All residents and employees who have no medical contraindications to the vaccine will be offered the influenza vaccine annually to encourage and promote the benefits associated with vaccinations against Influenza . 6. A resident's refusal of the vaccine shall be documented on the informed consent for influenza vaccine and placed in the resident's medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the facility was maintained in a safe, clean, homelike environment when:
1. One of two observed bathrooms had a clogged toilet, and two of two observed bathrooms needed sanding and painting. This failure resulted in unsanitary and unsafe conditions for the residents.
2. The kitchen temperature was too hot for three of three kitchen staff (Interim Dietary Supervisor [IDS], Dietary Staff [DS 1 and DS 2]) . This failure had the potential to result in facility kitchen staff experiencing heat-exposure related injuries.
Findings:
1. During an observation on 4/15/24 at 11:01 a.m. in the shared bathroom between rooms [ROOM NUMBERS], there was a damp towel on the floor wrapped around the base of the toilet. There was bubbling and peeling paint on the wall next to the toilet. The lower 1/3 of the metal door frame near the toilet was black and orange. There was a plunger next to the toilet.
During an observation on 4/15/24 at 11:05 a.m. in the shared bathroom between rooms [ROOM NUMBERS], there was bubbling and peeling paint on the wall next to the toilet. The lower 1/3 of the metal door frame near the toilet was black and orange.
During an interview on 4/15/24 at 11:10 a.m. with Resident 61, Resident 61 stated the toilet in his bathroom is clogged and overflows. He stated there's water all over the floor. He stated he must use a plunger to unclog the toilet.
During a concurrent observation and interview on 4/17/24 at 8:16 a.m. with Director of Maintenance (DM) in the bathroom between rooms [ROOM NUMBERS], there was a moist, brown colored substance on the floor around the toilet. There was bubbling and peeling paint on the wall next to the toilet. The lower 1/3 of the metal door frame near the toilet was black and orange. There was a plunger next to the toilet. DM stated he needed to clear out the plumbing, sand the peeling paint off the walls, sand off the rust on the door frame and paint.
During a review of the facilities policy and procedure (P&P) titled, Maintenance Services, revised 8/2020, the P&P indicated, I. The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. II. Functions of the Maintenance Department may include .Maintaining the heat/cooling system, plumbing fixtures, wiring, etc., in good working order.
During a review of the facilities P&P titled, Resident Rooms and Environment, revised 8/2020, indicated, The Facility provides residents with a safe, clean, comfortable, and homelike environment .I. Facility Staff aim to create a personalized, homelike atmosphere, paying close attention to the following: A. Cleanliness and order.
During a review of the facilities P&P titled, Supervision, Maintenance Services, revised 5/2008, the P&P indicated, 2. The Maintenance Director is responsible for scheduling preventative maintenance service.
2. During a concurrent observation and interview on 4/15/24 at 9:36 a.m. with IDS in the facility kitchen, the kitchen temperature felt warm and the temperature on the thermostat was 74 degrees Fahrenheit. IDS stated, It feels warmer than that [74 degrees]. It gets really warm in here. Its an old kitchen and there is poor ventilation.
During a interview on 4/15/24 at 9:37 a.m. with DS 1, DS 1 stated, It gets really hot in here especially when the ovens are on. I have seen it get as high as 90 degrees Fahrenheit plus. In the summer when it's in the 100's [degrees] outside its so hot, it gets unbearable in here.
During a concurrent observation and interview on 4/17/24 at 4:00 p.m. with DS 2 in the facility's kitchen, the kitchen temperature was 81 degrees Fahrenheit. DS 2 stated it feels warm in here right now. DS 2 stated the kitchen can get very hot in the summer, with the thermostat reading up to 90 degrees.
During a concurrent observation and interview on 4/17/24 at 4:01 p.m. with DM, in the kitchen, the kitchen thermostat was at 81 degrees Fahrenheit. DM stated the air conditioner was serviced last Friday and it should be working now. DM stated the thermostat is currently at 81 degrees Fahrenheit, and it is warm in the kitchen.
During an interview on 4/18/24 at 9:52 a.m. with Administrator, the Administrator stated, We don't have a specific policy related to the temperature in the facility or the kitchen. We like it to stay around 78 [degrees]. Administrator was informed the thermostat was reading 81 degrees Fahrenheit yesterday afternoon at 4 p.m. Administrator stated that is not an acceptable temperature, that would not be comfortable. Administrator stated, I cannot get the temperature down in the kitchen with those ovens going and everything, especially in the summer and as hot as it gets.
Facility policy related to Kitchen Temperature was requested, and none was provided.

Based on interview and record review, the facility failed to revise a care plan for one of three sampled residents (Resident 2) when staff placed Resident 2 on the floor to prevent a fall. This failure resulted in staff being unaware of how to care for Resident 2.
Findings:
During a review of Resident 2's admission Record (AR), dated 3/7/24, the AR indicated, admission Date 12/8/23.Diagnosis.unspecified dementia (progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change).
During a review of Resident 1's Care Plan (CP), dated 12/24/2023, the CP indicated, [Resident 2] is high risk for falls r/t [related to] confusion, gait/balance problems, poor communication/comprehension, unaware of safety needs.Date initiated: 12/24/23.Interventions.Anticipate and meet the resident's needs.Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance.Continuous direct supervision 1:1.encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility.Ensure that the resident is wearing appropriate foot wear when ambulating or mobilizing in w/c [wheel chair].Follow facility protocol.Place floor mat to the left of his bed while in bed.The resident needs a safe environment with even floors free from spills and/or clutter, adequate, glare-free light, a working and reachable call light, the bed in low position at night.handrails on walls, personal items within reach.
During a review of the S [Situation] B [Background] A [Appearance] R [Review and Notify] Communication Form (SBAR-used to notify the physician of a change of condition), dated 2/29/24, the SBAR indicated, [Resident 2] was placed on the floor to prevent resident from falling.
During a review of Resident 2's Progress Notes (PN), dated 2/29/24, the PN indicated, Abuse allegation. IDT [Interdisciplinary Team (brings together knowledge from different health care disciplines to help people receive the care they need) initiated an allegation of abuse towards [Resident 2].IDT found that during night shift [Resident 2] was placed on the floor by staff. During investigation Nurse verbalized that I instructed staff to place blankets on the floor and pillow, and then lower [Resident 2], to prevent him from falling or any injury. [Resident 2] would stay on the floor for about 15-30 minutes and then would be placed back to the bed.
During an interview on 3/7/24 at 12:49 p.m., with Director of Nursing (DON), DON stated on 2/29/24 Hospitality Aide (HA) 1, reported there were two occasions where Licensed Vocational Nurse (LVN) 2 had ordered staff to place Resident 2 on the floor with blankets and pillows when he was trying to get out of the bed or wheelchair to prevent Resident 2 from falling. DON stated HA 1 was unable to give exact dates but stated he had witnessed it twice.
During an interview on 3/7/24 at 1:13 p.m., with Administrator, Administrator stated when she interviewed LVN 2 regarding placing Resident 2 on the floor to prevent a fall, LVN 2 stated she had instructed staff to place Resident 2 on the floor to prevent him from falling from the bed and wheelchair.
During an interview on 3/8/24 at 4:17 a.m., with LVN 2, LVN 2 stated she had instructed staff to put Resident 2 on the floor, on two different occasions (no dates given) to prevent him from falling when he was very agitated. LVN 2 stated when staff would place Resident 2 in bed he would try to get up and when he was put in the wheelchair, he would push staff away and staff could not keep him in his wheelchair. LVN 2 stated she had directed staff to place Resident 2 on the floor to prevent him from falling and sustaining an injury. LVN 2 stated it should have been a care plan intervention to put Resident 2 on the floor when he was trying to get out of bed and out of his wheelchair when agitated.
During an interview on 3/8/24 at 4:49 a.m., with Certified Nursing Assistant (CNA 2), CNA 2 stated she assisted with placing Resident 2 on the floor when he was agitated. CNA 2 stated Resident 2 was throwing his feet off the bed to get out and when he was up in his wheelchair, he was trying to slide out of the wheelchair by leaning his head forward at ground level. CNA 2 stated Resident 2 was on the floor in the hallway on pillows and blankets for approximately 20 minutes.
During an interview on 3/8/24 at 4:57 a.m., with CNA 3, CNA 3 stated he had seen Resident 2 placed on the floor twice but was unsure of the dates. CNA 3 stated he was very agitated and was grabbing and digging his fingernails in staff and throwing his legs over the bed to try and get up and walk. CNA 3 stated Resident 2 was placed on the floor in his room one time and the other time he was placed on the floor in the hallway. CNA 3 stated he was told by another staff it was ok to put Resident 2 on the floor because the intervention was care planned.
During an interview on 3/8/24 at 5:07 a.m., with CNA 4, CNA 4 stated she had seen Resident 2 placed in the floor on one occasion to prevent him from falling. CNA 4 stated LVN 2 instructed the staff to place Resident 2 on the floor. CNA 4 stated, she thought it was care planned.
During an interview on 4/8/24 at 9:20 a.m., with DON, DON stated Resident 2's care plan was not followed when Resident 2 was placed on the floor to prevent a fall. DON stated when the current interventions were not working staff should have notified the IDT and the care plan should have been revised with new interventions.
During a review of the facility's policy and procedure (P&P), titled Falls and Fall Risk, Managing dated 3/2018, the P&P indicated, Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling.The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each.The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling.If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions.

Based on interview and record review, the facility failed to implement its policy and procedure (P&P) when an outbreak was not reported when six of eight sampled residents (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, and Resident 6) were diagnosed with scabies (a contagious skin disease marked by itching and small raised red spots, caused by the itch mite). This failure resulted in the state health department being unaware of the outbreak.
Findings:
During a review of Resident 1 ' s Integumentary Assessment Sheet (completed by Physician 1) (IAS), dated 1/11/24, the IAS indicated, Pt [Patient] seen exam bedside with generalized pruritic (severe itching) macule (flat, distinct, discolored area of skin) papule (small, well-defined bump in the skin) rash over trunk and upper extremities with tracking (trail or a path) without burrowing (move underneath by digging or making a hole to hide) with ddx (differential diagnosis) scabies.
During a review of Resident 2 ' s IAS (completed by Physician 1), dated 1/11/24, the IAS indicated, Pt seen exam bedside with generalized pruritic maculopapular rash over trunk/extremities without burrowing or tracking ddx scabies.
During a review of Resident 3 ' s IAS (completed by Physician 1) (IAS), dated 1/11/24, the IAS indicated, Pt seen exam bedside with generalized pruritic scab and excoriated maculopapular/pruritic over trunk and . B/L (bilateral-both) upper extremities with clinical dx (diagnosis) of scabies.
During a review of Resident 4 ' s IAS (completed by Physician 1), dated 1/25/24, the IAS indicated, Pt seen exam bedside with generalized pruritic maculopapular rash to trunk and B/L LE (lower extremities) with tracking without burrowing.dx of scabies.
During a review of Resident 5 ' s IAS (completed by Physician 1), dated 1/25/24, the IAS indicated, Pt seen exam bedside with generalized pruritic maculopapular rash and excoriation to trunk and extremities without burrowing some tracking with clinical.dx of scabies.
During a review of Resident 6 ' s IAS (completed by Physician 1), dated 1/25/24, the IAS indicated, Pt seen exam bedside with generalized pruritic maculopapular rash mainly trunk area with tracking no burrowing clinical dx of scabies.
During an interview on 1/30/24 at 10:51 a.m., with Infection Preventionist (IP), IP stated the scabies outbreak was not reported to the state health department because there was no confirmed skin scraping (specimen of a suspected lesion which is sent to a laboratory for identification).
During an interview on 1/30/24 at 1:45 p.m., with Director of Nursing (DON), DON stated the scabies outbreak should have been reported to the state health department when there was three or more of the same occurrences.
During a review of the California Department of Public Health Prevention and Control of Scabies in California Healthcare Setting dated 8/2020, the guidance indicated, An outbreak should be assumed to be occurring following diagnosis of a single case, until screening of all new patients and staff for scabies has been completed without identifying additional suspect cases. An outbreak cannot be conclusively excluded for at least 6 weeks following the last unprotected exposure to the case.
During a review of the facility ' s P&P titled, Reporting Communicable Diseases revised 7/14, the P&P indicated, The Infection Preventionist is responsible for notifying the local, district, or state health department of confirmed cases of state-specific reportable diseases.
During a review of the facility ' s P&P titled, Outbreak of Communicable Diseases revised 9/22, the P&P indicated, An outbreak is defined as one of the following.Occurrence of three (3) or more cases of the same infection over a specified period of time and in a defined area.The administrator s responsible for: communicating data about reportable diseases to the health department.

Based on interview and record review, the facility failed to ensure the physician was notified when four of eight sampled residents (Resident 1, Resident 2, Resident 4, and Resident 5) presented with rashes. This failure resulted in a delay of care and the potential for scabies (a contagious skin disease marked by itching and small raised red spots, caused by the itch mite) to spread to other residents, staff, and visitors.
Findings:
1a. During a review of Resident 1 ' s Shower Day Skin Inspection (SDSI), dated 1/3/24, the SDSI indicated, Rash: chest, arms, back. The SDSI was signed by Certified Nursing Assistant (CNA) 1 and Licensed Vocational Nurse (LVN) 1.
During a review of Resident 1 ' s SDSI dated 1/6/24, the SDSI indicated, Rash: see below. The body diagram had a rectangle around the front torso and the right side of the back, with rash documented on the sheet. The SDSI was signed by CNA 2 and LVN 1.
During a review of Resident 1 ' s S (Situation) B (Background) A (Appearance) R (Review and Notify) (SBAR-used to notify the Physician of a change of condition), dated 1/9/24, the SBAR indicated, Other change in condition: rash to abd (abdomen), arms and hands.this started on 1/9/24 (6 days after the rash was documented on the SDSI).
During a concurrent interview and record review on 2/9/24 at 1:29 p.m., with LVN 1, LVN 1 stated Resident 1 ' s SDSI dated, 1/3/24 and 1/6/24 was reviewed. LVN 1 stated when she was informed of the rash and signed the SDSI, she should have notified the physician of Resident 1 ' s change of condition.
1b. During a review of Resident 2 ' s SDSI dated 1/3/24, the SDSI indicated, Rash. The body diagram had a circle around the front left side of the chest and upper left arm. The SDSI was signed by CNA 3.
During a review of Resident 2 ' s SBAR dated 1/8/24, the SBAR indicated, Other change in condition: rash to resident ' s abdomen.this started on 1/8/24 (5 days after the rash was documented on the SDSI).
1c. During a review of Resident 4 ' s SDSI dated 1/18/24, the SDSI indicated, Reddened area: scabs and redness all over. The entire body diagram was circled front and back indicating the areas were covering the whole body. The SDSI was signed by CNA 4.
During a review of Resident 4 ' s SBAR dated 1/25/24, the SBAR indicated, Other change in condition: Clinical diagnosis of scabies.This started on 1/25/2024 (7 days after the reddened areas were documented on the SDSI)
During a concurrent interview and record review on 2/9/24 at 2:22 p.m., with LVN 2, Resident 4 ' s SDSI dated 1/18/24, was reviewed. LVN 2 stated when he was informed of the rash, he should have notified the physician of Resident 4 ' s change of condition.
1d. During a review of Resident 5 ' s SDSI dated 1/9/24, the SDSI indicated, Rash: yes full body.
During a review of Resident 5 ' s SDSI dated 1/19/24, the SDSI indicated, Rash: All over body. The entire body diagram was circled front and back indicating the areas were covering the whole body and rash was documented between the full body diagrams. The SDSI was signed by CNA 4.
During a review of Resident 5 ' s SBAR (SBAR) dated 1/25/24, the COC indicated, This started on 1/25/2024 (16 days after the rash was documented on the SDSI).Recommendations of Primary Clinicians.hydroxyzine (medication used for itchiness).Permethrin (medication used to treat scabies) External Cream.Apply to neck to toes topically one time only 8-14 hrs (hours) then wash off for clinical diagnosis of scabies.
During an interview, on 1/29/24 at 1:03 p.m., with Director of Nursing (DON), DON stated when the skin changes were noted on the SDSI ' s for Resident 1, Resident 2, Resident 4 and Resident 5, the nurses should have done a change of condition and notified the physician.
During a review of the facility ' s policy and procedure (P&P) titled, Change in a Resident ' s Condition or Status dated 2/2021, the P&P indicated, The nurse will notify the resident ' s attending physician or physician on call when there has been a(an).need to alter the resident ' s medical treatment significantly.A significant change of condition is a major decline or improvement in the resident ' s status that: a. will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 9) Responsible Party (RP) was provided with Resident 9 ' s medical record when requested. This failure resulted in a delay of the medical record being provided.
Findings:
During an interview on 2/9/24 at 8:42 a.m., with Family Member (FM) 1, FM 1 stated she was Resident 9's RP and had requested the medical record for Resident 9 several times since November 2023. FM 1 stated, when she requested the medical record the medical record release form was to be e-mailed to her and the facility never sent the e-mail.
During an interview, on 2/9/24 at 11:37 a.m., with Medical Records Supervisor (MRS), MRS stated she had heard Resident 9 ' s RP wanted medical records and e-mailed the medical record release form to FM 1 but had never received the completed request back. MRS was unable to provide evidence the medical request form was provided to FM 1.
During an interview, on 2/9/24 at 11:52 a.m., with the Social Services Director (SSD), SSD stated Director of Nursing (DON) spoke with FM 1 on the phone with SSD present. FM 1 requested Resident 9 ' s medical records and the DON e-mailed the medical records with the request.
During an interview, on 2/9/24 at 12:15 p.m., with DON, DON stated FM 1 had requested Resident 9 ' s medical record. DON stated it was the responsibility of the medical records staff to follow up and provide the request for medical record release form to the RP. DON stated she informed MRS of the request. DON was unable to provide evidence the request form was provided to FM 1.
During a review of the facility ' s policy and procedure (P&P) titled, Release of Information dated 11/2009, the P&P indicated, The resident may initiate a request to release such information contained in his/her records and charts to anyone he/she wishes. Such requests will be honored only upon the receipt of a written, signed, and dated request from the resident or representative (sponsor).A resident may obtain photocopies of his or her records by providing the facility with at least a forty-eight (48) hour (excluding weekends and holidays) advance notice of such request.

Based on interview and record review, the facility failed to follow its policy and procedure on Resident-to-Resident Altercations for one of two sampled residents (Resident 1). This failure resulted in Resident 2 hitting Resident 1.
Findings:
During a review of the facility ' s Self Report of Resident-to-Resident Altercation (SRRRA), dated 1/16/24, the SRRRA indicated, On 1/14/2024 at approximately 5:00 a.m., staff reported that while redirecting (Resident 2) ' s behavior towards (Resident 1), (Resident 2) made contact with (Resident 1) on the face with a closed fist as both CNA (Certified Nursing Assistant 1) and (Resident 1) attempted to exit the room.
During a review of Resident 1's Brief Interview for Mental Status (BIMS), dated 9/11/23, the BIMS indicated, BIMS Summary Score 4.Severe cognitive impairment.
During a review of Resident 2's Brief Interview for Mental Status (BIMS), dated 8/10/23, the BIMS indicated, BIMS Summary Score 4.Severe cognitive impairment.
During an interview on 1/17/24 at 5:22 p.m., with CNA 1, CNA 1 stated she was assigned to Resident 1 and Resident 2 during the night shift of 1/13/24, she was instructed to keep the doors to the resident rooms open during the night for resident safety. CNA 1 stated, during the night when she would open the door to Resident 1 and Resident 2 ' s room, Resident 2 would aggressively close the door. CNA 1 stated, when she was in the hall, the door to Resident 1 and Resident 2 ' s room was shut, and she heard Resident 1 say ow you're hitting me in the chest. CNA 1 stated, when she heard Resident 1, she opened the door and redirected Resident 1 out of the room and into the hall. CNA 1 stated, approximately 15 minutes later she noticed the door to Resident 1 and Resident 2 ' s room was closed again. CNA 1 stated, when she opened the door, she seen both Resident 1 and Resident 2 in each other ' s face and when she was attempting to redirect Resident 1 out of the room, Resident 2 hit (CNA 1) and then hit Resident 2 on the jawline. CNA 1 stated, she was not aware Resident 1 had returned to the room.
During an interview on 1/26/24 at 1:36 p.m., with Director of Nursing (DON), DON stated, when the first allegation was overheard Resident 1 and Resident 2 should have been separated rooms to prevent any further altercation.
During a review of the facility ' s policy and procedure titled, Resident-to-Resident Altercations dated 9/2022, the P&P indicated, If two residents are involved in an altercation, staff: a. separate the residents, and institute measures to calm the situation.

Based on observation, interview, and record review, the facility failed to provide care for one of three sampled residents (Resident 1), when Resident 1 was not immediately assessed, and Attending Physician (AP) was not notified of Resident 1 ' s unwitnessed fall. This failure resulted in a delay in treatment for Resident 1.
Findings:
During an interview on 12/28/23 at 10:45 a.m. with Director of Nurses (DON), DON stated on 12/24/23 at approximately 2:51 p.m. Licensed Vocational Nurse (LVN 1) had noted discoloration to Resident 1 ' s left inner eye. DON stated upon further investigation, on 12/23/23 during a.m. shift, Hospitality Aid (HA) had found Resident 1 in a sitting position on the floor next to his bed. DON stated Resident 1 ' s AP was not notified of the fall on 12/23/23 and no assessment was completed.
During an interview on 12/28/23 at 11:20 a.m. with LVN 1, LVN 1 stated on 12/24/23, Resident 1 ' s left outer eye had purple discoloration. LVN 1 stated Resident 1 may have hit the night stand causing the discoloration to his left eye.
During an interview on 12/28/23 at 11:29 a.m. with LVN 2, LVN 2 stated he was the assigned nurse for Resident 1 on 12/23/23. LVN 2 stated he was made aware of Resident 1 being found on the floor next to his bed on 12/23/23. LVN 2 stated he did not complete a full body assessment and did not notify the AP when Resident 1 was found on the floor next to his bed on 12/23/23.
During an interview on 12/28/23 at 12:33 p.m. with HA, HA stated on 12/23/23, Resident 1 was found sitting on the floor next to his bed. HA stated he did not know how Resident 1 fell off the bed. HA stated he had immediately reported Resident 1 ' s fall on 12/23/23 to his assigned nurse (LVN 2).
During a review of the facility ' s policy and procedure (P&P) titled, Change in a Resident ' s Condition or Status, dated 2/21, the P&P indicated, 1. The nurse will notify the resident ' s attending physician or physician on call when there has been a(an): a. accident or incident involving the resident;.2. Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR Communication Form.

Based on interview and record review, the facility failed to ensure the medical record was complete for one of three sampled residents (Resident 1). This failure resulted in an incomplete medical record.
Findings:
1. During a concurrent interview and record review, on 12/7/23, at 1:22 p.m., with Director of Nursing (DON), Resident 1 ' s Weekly Summary (WS) assessments were reviewed. DON was unable to provide WS documentation for the weeks of 1/8/23-1/14/23, 1/22/23-1/28/23, 1/29/23-2/4/23, 2/5/23-2/11/23, 2/12/23-2/18/23, 3/19/23-3/25/23, 3/26/23-4/1/23 and 4/2/23-4/8/23. DON stated, weekly summaries should have been done by the nurse during the shift it was assigned.
2. During a concurrent interview and record review, on 12/14/23, at 1:43 p.m., with DON, Resident 1 ' s Documentation Survey Report (DSR), dated 2/2023 was reviewed. The DSR indicated, Bathing/Shower days are Monday and Thursday. There was no documentation indicating Resident 1 was provided a shower on 2/2/23. DON stated, when the shower was provided it should have been documented or it was not given.
During a review of the facility ' s policy and procedure (P&P) titled, Documentation in Medical Record dated 2023, the P&P indicated, Documentation shall be completed at the time of service, but no later than the shift in which the assessment, observation, or care service occurred.

Based on interview and record review, the facility failed to ensure the physician was notified for one of three sampled residents (Resident 1) when Resident 1 was not administered prescribed medications. This failure had the potential for Resident 1 to have adverse side effects.
Findings:
During a review of Resident 1 ' s Medication Administration Record (MAR), dated April 2023, the MAR indicated, Clonidine patch (used to treat high blood pressure) weekly.apply one patch transdermally [to the skin] one time a day every Mon [Monday].Spironolactone (used to remove excess fluid).give 1 tablet by mouth one time a day.Venlafaxine (used to treat depression).give 1 tablet by mouth one time a day.Coreg (used to treat high blood pressure).give 1 tablet by mouth two times a day.lasix (used to remove excess fluid).give 1 tablet by mouth two times a day.risperdal (used to improve mood, thoughts and behaviors).give 2 mg [milligrams] by mouth two times a day.Seroquel (used to treat mental health conditions).give 1 tablet by mouth two times a day.Hydralazine (used to treat high blood pressure).give 1 tablet by mouth three times a day. Clonidine patch was not administered on 4/3/23 and 4/10/23. Spironolactone was not administered on 4/3/23 and 4/4/23. Venlafaxine was not administered 4/3/23 and 4/4/23. Coreg was not administered on 4/1/23, 4/2/23, 4/10/23, 4/11/23, and 4/12/23. Lasix was not administered on 4/1/23, 4/2/23, 4/11/23 and 4/12/23. Risperdal was not administered on 4/6/23, 4/7/23, 4/8/23, 4/11/23 and 4/12/23. Hydralazine was not administered on 4/6/23, 4/7/23, 4/8/23, 4/12/23 and 4/13/23. There was no documentation that the physician was notified of the medication not being administered.
During a concurrent interview and record review on 12/14/23, at 1:43 p.m., with Director of Nursing (DON), DON reviewed Resident 1 ' s clinical record. DON was unable to provide evidence that the physician was notified of the unadministered medications. DON stated, the nurse should have notified the physician when the medication was not administered.
During a review of the facility policy and procedure (P&P) titled Change in a Resident ' s Condition or Status revised 2/21, the P&P indicated, The nurse will notify the resident ' s attending physician or physician on call when there has been a(an).refusal of treatment or medications (2) or more consecutive times.

Based on interview and record review, the facility failed to ensure the plan of care was implemented and/or updated after a fall for two of three sampled residents (Resident 1 and Resident 2). This failure had the potential for the residents to fall again.
Findings:
1. During a review of Resident 1 ' s Progress Notes (PN), dated 5/27/22 at 10:20 a.m., the PN indicated, [Resident 1] was on the ground in bathroom in sitting position.IDT [Interdisciplinary Team- members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities] Recommendations.offer toileting after meals.
During a review of Resident 1 ' s Care Plan (CP), dated 5/27/22, the CP indicated, On 5.26.2022 [Resident 1] was found sitting on the floor of his bathroom.Date Initiated: 5/27/2022.Interventions.offer toileting after meals.
During a concurrent interview and record review, on 12/14/23 at 1:43 p.m., with Director of Nursing (DON), Resident 1 ' s Documentation Survey Report (DSR), dated May 2022 and June 2022, was reviewed. There was no documentation indicating Resident 1 was toileted after each meal on 5/27, 5/28, 5/29, 5/30, 6/1, 6/3, 6/4, 6/5, 6/7, 6/8, 6/9, 6/11, 6/13, 6/16, 6/17, 6/19, 6/20, 6/22, 6/24, 6/27, 6/28 and 6/29. DON stated, Resident 1 should have been toileted after each meal, and it should have been documented.
2. During a review of Resident 2 ' s IDT – Interdisciplinary Post Event Note (IDT) dated 10/25/23, the IDT indicated, Staff heard a noise and went to respond, upon entering room Resident was noted to be on her left side with left arm under her next to window. IDT Recommendations: Monitor for pain and discomfort. Monitor for delayed injury. Give pain medications as needed per sliding scale. Reach out to Hospice (provide care to sick or terminally ill) to provide possible bed with bolsters.
During a concurrent interview and record review on 12/7/23, at 1:22 p.m., with Director of Nursing (DON), Resident 2 ' s Care Plans were reviewed. DON was unable to provide an updated care plan after Resident 2 ' s fall on 10/25/23. DON stated, the Care Plan should be updated after each fall with the new interventions.
During a review of the facility ' s policy and procedure (P&P) titled, Falls and Fall Risk, Managing revised 3/2018, the P&P indicated, If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions.
During a review of the facility ' s policy and procedure (P&P) titled, Goals and Objectives, Care Plans revised 2009, the P&P indicated, Goals and objectives are entered on the resident ' s care plan so that all disciplines have access to such information and are able to report whether or not the desired outcomes are being achieved.Goals and objectives are reviewed and/or revised: a. when there has been a significant change in the resident ' s condition; b. when the desired outcome has not been achieved; c. when the resident has been readmitted to the facility from a hospital/rehabilitation stay; and d. at least quarterly.

Based on observation, interview, and record review, the facility failed to ensure two of two sampled staff (Dietary Aide [DA] 1 and Certified Nursing Assistant [CNA] 1) wore their N95 mask (respiratory device designed to achieve a very close facial fit and very efficient filtration of airborne particles) properly. This failure had the potential for residents, staff, and visitors to be at risk for contracting COVID 19.
Findings:
During a concurrent observation and interview, on 10/11/23, at 5:01 p.m., with Dietary Aide (DA) 1, DA 1 was observed pushing the resident food cart down the hall wearing an N95 mask. The two straps on the N95 were cut, and tied together and then looped around each ear. DA 1 stated, she was wearing the N95 due to a COVID 19 outbreak in the facility but had modified the N95 straps because it hurt her head.
During a concurrent observation and interview, on 10/11/23, at 5:03 p.m., with Certified Nursing Assistant (CNA) 1, CNA 1 was observed coming out of a resident's room wearing an N95 mask below her nose and the two straps had been cut and tied together and looped around each ear. CNA 1 stated, she was to wear the N95 mask to protect her from COVID 19 during the facility outbreak but she had manipulated the mask and tied it around her ears because it was hard for her to breathe with it on properly.
During an interview on 10/26/23, at 11:20 a.m., with Director of Staff Development (DSD), DSD stated, when wearing the N95 mask properly, one strap should be around the head and the second strap should be around the neck to cover the mouth and nose. DSD stated the N95 mask should not have been manipulated.
During a review of the facility's policy and procedure (P&P) titled, Respiratory Protection dated 2020, the P&P indicated, Proper Respirator Use.Employees will use their respirator under conditions specified by this program, and in accordance with the training they receive on the use of the selected model(s).

Based on observation, interview, and record review, the facility failed to follow the therapeutic menu when cornbread was not served as indicated for five of five sampled residents (Resident 1, Resident 2, Resident 3, Resident 4, and Resident 5). This failure had the potential for the residents to have unmet nutritional needs.
Findings:
During a review of the Summer Menu (SM), dated 6/15/23, the SM indicated, Roast Pork Loin with spiced apples, ranch style beans, southern style green beans, parsley sprig, corn bread 2x2 1/2, margarine, vanilla mousse choc (chocolate) chip garnish, milk were to be served for lunch.
During a concurrent observation and interview on 10/5/23 at 12:20 p.m. in the restorative dining room, with Certified Nursing Assistant (CNA) 1, Resident 2, Resident 3, Resident 4, and Resident 5's lunch was observed. None of the residents were served cornbread. CNA 1 stated none of the residents were served cornbread.
During a concurrent observation and interview on 10/5/23, at 12:30 p.m. with Resident 1, in the dining room, Resident 1 was served a pork chop, rice, green beans and butter. There was no cornbread served to Resident 1. Resident 1 stated she did not receive any cornbread.
During an interview on 10/5/23, at 12:45 p.m. with [NAME] (CK), CK stated the therapeutic menu for the lunch meal that day (10/5/23) included cornbread. CK stated cornbread was not served that day due to being burned and an alternate was not served. CK stated an alternate should have been provided.
During an interview on 10/26/23 at 1:50 p.m. with Certified Dietary Manager (CDM), CDM stated when the cornbread was not available there should have been a substitute provided. CDM stated when the therapeutic menu was not followed it could result in the residents not receiving adequate nutrition.
During a review of the facility's policy and procedure (P&P) titled, Food Substitutions During Trayline dated 2020, the P&P indicated, The cook will provide a food substitute at each meal for a food item .

Based on interview and record review, the facility failed to ensure Physician's Orders (PO) were implemented for one of three sampled residents (Resident 1). This failure had the potential for Resident 1 to have an increase in behavior symptoms.
Findings:
During a review of Resident 1's S [situation] B [background] A [Appearance] R [Review and Notify] (SBAR-used to notify physician of a change of condition) dated 9/9/23, the SBAR indicated, Other res [resident] accused [Resident 1] of hitting her in the face.
During a concurrent interview and record review on 9/13/23 at 11:55 p.m., with Director of Nursing (DON), Resident 1's clinical record was reviewed. The PO dated 9/11/23 was reviewed. The PO indicated, D/C [discontinue] Zyprexa (medication used to treat mental health conditions) [5 mg twice a day].Start Zyprexa 5 mg [milligrams-unit of measurement] po [by mouth] 6 am & 7.5 mg po QHS [at bedtime] . DON was unable to provide evidence of the PO was being implemented. DON stated the PO should have been implemented.
During a concurrent interview and record review on 9/13/23 at 12 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 reviewed Resident 1's PO and stated the old Zyprexa order was discontinued but the new order was not implemented. LVN 1 stated the PO should have been implemented.
During a review of the facility's policy and procedure (P&P) titled, Medication Orders dated 6/1/22, the P&P indicated, Documentation of Medication Orders: a. Each medication order should be documented with the date, time, and signature of the person receiving the order. The order should be recorded on the physician order sheet, and the Medication Administration Record (MAR).
Based on interview and record review, the facility failed to ensure Physician's Orders (PO) were implemented for one of three sampled residents (Resident 1). This failure had the potential for Resident 1 to have an increase in behavior symptoms.
Findings:
During a review of Resident 1's S [situation] B [background] A [Appearance] R [Review and Notify] (SBAR-used to notify physician of a change of condition) dated 9/9/23, the SBAR indicated, Other res [resident] accused [Resident 1] of hitting her in the face.
During a concurrent interview and record review, on 9/13/23 at 11:55 p.m., with Director of Nursing (DON), Resident 1's clinical record was reviewed. The handwritten Physician's Orders (PO) dated 9/11/23 was reviewed. The PO indicated, D/C [discontinue] Zyprexa (medication used to treat mental health conditions) .Start Zyprexa 5 mg [milligrams-unit of measurement] po [by mouth] 6 am & 7.5 mg po QHS [at bedtime] . DON was unable to provide evidence of the Physician's Order being implemented. DON stated, the Physician's Order should have been implemented.
During a concurrent interview and record review, on 9/13/23 at 12 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 reviewed Resident 1's PO's and stated, the old Zyprexa order was discontinued but the new order was not implemented. LVN 1 stated, the PO should have been implemented.
During a review of the facility's policy and procedure (P&P) titled, Medication Orders dated 6/1/22, the P&P indicated, Documentation of Medication Orders: a. Each medication order should be documented with the date, time, and signature of the person receiving the order. The order should be recorded on the physician order sheet, and the Medication Administration Record (MAR).

Based on observation, interview, and record review, the facility failed to provide necessary care and services according to the care plan for one of three sampled residents (Resident 1) when Resident 1 was not supervised by staff when walking down the hallways. This failure resulted in Resident 1 being found outside of the facility alone.
Findings:
During an observation on 8/2/23, at 10:55 a.m., Resident 1 was observed in [Resident 1] ' s room sitting on the bed.
During a review of Resident 1 ' s S [Situation] B [Background] A [Appearance] R [Review and Notify] Communication Form (SBAR), dated 8/1/23, the SBAR indicated, Elopement (the act of leaving secretly); found outside of facility.
During a review of Resident 1 ' s Elopement Evaluation (EE), dated 7/19/23 at 5:59 p.m., the EE indicated, Does the resident wander.Yes.
During a review of Resident 1 ' s Care Plan (CP), dated 2/11/23, the CP indicated, I am at risk for elopement not being able to make good safety decisions.Goal.I will remain safe within my unit thru my next review.Interventions/Tasks.Find something on the unit I would like to do to divert my attention from the door.Talk to me to try to find out what I ' m looking for.Walk with me through the unit.
During an interview on 8/2/23, at 1:02 p.m., with Director of Nursing (DON), DON stated, on 8/1/23 at approximately 10:45 p.m., night shift staff was arriving to the facility and one of the oncoming Certified Nursing Assistants (CNA 2) noticed Resident 1 standing outside of the facility on the sidewalk. DON stated, Resident 1 exited the facility during change of shift when staff were coming and going and none of the staff seen Resident 1 exited the facility. DON stated, prior to Resident 1 being found outside, there was a pharmacy delivery and the delivery driver had exited the building one to two minutes prior to Resident 1 being found alone outside.
During an interview on 8/21/23, at 9:30 p.m., with CNA 1, CNA 1 stated, on 8/1/23, at approximately 10:45 p.m., [CNA 1] clocked out and was exiting the facility when CNA 2 was entering the facility and reported there was a person standing outside. CNA 1 stated, Resident 1 was standing outside alone on the cement staring up at the sky. CNA 1 stated, Resident 1 will try and exit the facility if [Resident 1] can see the door open. CNA 1 stated, the night Resident 1 exited the facility the pharmacy staff had the code to the door and let themselves out of the facility. CNA 1 stated, the pharmacy staff are prone to not looking behind them when they exit the facility to make sure the door shuts.
During an interview on 8/22/23, at 5:53 a.m., with Licensed Vocational Nurse (LVN 1), LVN 1 stated, prior to Resident 1 being found alone outside the facility, [LVN 1] seen Resident 1 walking down the hallway at approximately 10 p.m. LVN 1 stated, while [LVN 1] was trying to calm down another resident, Resident 1 left the area. LVN 1 stated, Resident 1 was found alone outside the facility at approximately 10:45 p.m. LVN 1 stated, at times Resident 1 will stand at the door and staff would redirect [Resident 1]. LVN 1 stated, Resident 1 was probably standing and watching someone exit the door and pushed it open right behind them and exited the facility.
During an interview on 8/24/23, at 6 a.m., with CNA 2, CNA 2 stated, on 8/1/23, when arriving for work between 10:30 p.m. and 10:45 p.m., [CNA 2] seen Resident 1 standing alone outside of the facility.
During a review of the facility ' s policy and procedure (P&P) Elopements and Wandering Residents dated 6/1/22, the P&P indicated, This facility ensures that residents who exhibit wandering behaviors and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. Adequate supervision will be provided to help prevent accidents or elopements.

Based on observation, interview, and record review, the facility failed to ensure one of six sampled residents (Resident 1) was free from abuse when Resident 1 was tied down in her wheelchair with a blanket (draw sheet-a flat sheet used on top of the bed mattress) to prevent her from getting up. This failure had the potential for injury.
Findings:
During a review of the facility Investigation Report (IR), dated 8/8/23, the IR indicated, On August 3, 2023, at approximately 1830 [6:30 p.m.] hours, it was reported to the assisted director of nursing [ADON] that a staff member loosely tied a blanket around [Resident 1] while she was sitting in her wheelchair. This was witnessed by another staff member.
During an interview on 8/7/23 at 10:45 a.m. with Administrator and Director of Nurses (DON), Administrator stated on 8/3/23, Certified Nursing Assistant (CNA) 1 had taken Resident 1 in the dining room in her wheelchair with a blanket [draw sheet] tied around her wheelchair. Administrator stated CNA 2 had witnessed the incident. Administrator stated Resident 1 was a high risk for fall and CNA 1 had tied the blanket [draw sheet] around Resident 1's wheelchair to prevent Resident 1 from leaning forward, getting up, and falling. Administrator stated tying a resident with a blanket [draw sheet] was against facility abuse policy and considered a restraint.
During an interview on 8/7/23 at 11:16 a.m. with ADON, ADON stated on 8/3/23, it was reported to her CNA 1 had tied a blanket [draw sheet] behind Resident 1's wheelchair where Resident 1 cannot reach to untie. ADON stated CNA 1 had tied Resident 1 in her wheelchair with a blanket [draw sheet] to prevent her from getting up and falling. ADON stated tying a resident down is considered a restraint and is not allowed in the facility.
During a concurrent observation and interview on 8/7/23 at 11:34 a.m. with CNA 3 in Resident 1's room, Resident 1 sitting in a wheelchair, wearing a soft helmet. CNA 3 stated Resident 1 was at risk for falling and the soft helmet on Resident 1's head was used to prevent any head trauma in case of a fall. CNA 3 stated Resident 1 can get up on her own from her wheelchair, can walk but is unsteady.
During an interview on 8/7/23 at 6:45 p.m. with CNA 2, CNA 2 stated on 8/3/23, during dinner time, CNA 2 had walked in the dining room and noticed CNA 1 lowering Resident 1 back down into her wheelchair. CNA 2 stated as she got closer, she noticed a white blanket [draw sheet] was tied behind Resident 1's wheelchair. CNA 2 stated the blanket [draw sheet] was rolled in a belt form, placed across Resident 1's waist, and tied in a knot behind Resident 1's wheelchair. CNA 2 stated Resident 1 was unable to untie the blanket [draw sheet] and was unable to get up with the blanket [draw sheet] tied around her wheelchair. CNA 2 stated CNA 1 had tied Resident 1 in her wheelchair to prevent Resident 1 from trying to get out of her chair [wheelchair].
During an interview on 8/7/23 at 7:21 p.m. with Licensed Vocational Nurse (LVN), LVN stated the facility do not allow the use of any type of restraints. LVN stated Resident 1 did not have an order to be tied down with a blanket [draw sheet]. LVN stated CNA 1 tying Resident 1 with a blanket [draw sheet] was considered a restraint.
During an interview on 8/8/23 at 9:44 a.m. with Director of Staff Development (DSD), DSD stated Resident 1 being tied down in her wheelchair with a blanket [draw sheet] was considered a restraint and restraint is a type of abuse. DSD stated CNA 1 should not have tied Resident 1 down in her wheelchair.
During an interview on 8/8/23 at 9:58 a.m. with CNA 1, CNA 1 stated on 8/3/23, he was headed to the dining room for dinner, when he was approached by another staff (no name given) to take Resident 1 in the dining room. CNA 1 stated a blanket [draw sheet] had already been tied around Resident 1. CNA 1 stated during dinner time he was assisting other residents, when he noticed Resident 1 was trying to get up constantly from her wheelchair. CNA 1 stated he re-enforced the blanket [draw sheet] in a tighter knot to prevent Resident 1 from getting up and falling off her wheelchair. CNA 1 stated he had tied the blanket [draw sheet] like a grocery bag with a knot. CNA 1 stated the blanket [draw sheet] was around the wheelchair handle and tied behind Resident 1's back, it was like a seat belt. CNA 1 stated he had previously worked in the acute hospital and the prison and believed it was ' ok' to tie a resident.
During a review of Resident 1's Minimum Data Set (MDS-a standardized, comprehensive assessment tool) dated 4/20/23, the MDS indicated, Resident 1 had a BIMS [Brief Interview for Mental Status-which evaluates cognition, the ability to remember and think clearly] score of 4 (score range from 0 - 7 severe impairment).
During a concurrent interview and record review on 8/8/23 at 1:08 p.m. with DON, DON reviewed the facility's Policy and Procedure (P&P) titled, Abuse, Neglect and Exploitation, dated 6/1/22, DON stated CNA 1 did not follow the facility abuse policy and procedure when CNA 1 tied the blanket [draw sheet] around Resident 1's wheelchair to keep Resident 1 from getting up.
During a review of the facility's P&P titled, Abuse, Neglect and Exploitation, dated 6/1/22, the P&P indicated, Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement one of three sampled residents (Resident 1) Comprehensive Care Plan (a written plan developed by an interdisciplinary team [attending physician, registered nurse, dietician, etc.] and the resident, to help attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being) to prevent a fall incident when Resident 1 was left in the dining room without staff supervision. This failure resulted in Resident 1 falling and sustaining a right inferior orbital wall fracture (a break in the inner wall of the eye socket), requiring a transfer to an acute hospital.
Findings:
During a review of Resident 1's admission Record (AR), dated 8/3/23, the AR indicated, Resident 1 was admitted on [DATE], with diagnoses included Alzheimer's disease (type of dementia that damages the brain and affects memory, thinking, and behavior) and Dementia (condition that affect the brain's ability to think, remember and function normally).
During a review of Resident 1's quarterly Minimum Data Set (MDS - a standardized, comprehensive assessment tool) dated 5/12/23, the MDS indicated, Resident 1 had a BIMS (Brief Interview for Mental Status - which evaluates cognition, the ability to remember and think clearly) score of 0 (score range from 0 - 7 severe impairment). The MDS Section G 300 Balance During Transitions and Walking indicated, Resident 1 was Not steady, only able to stabilize with staff assistance when moving from seated to standing position and walking (with assistive device).
During a review of the facility Investigation Report (IR), dated 7/26/23, the IR indicated, On July 22, 2023, at approximately 1630 [4:30 p.m.] hours, [Resident 1] was on a 2 to 1 [two residents to one staff direct supervision at all times] with a staff member [Certified Nursing Assistant 1] and stated she [CNA 1] was in the dining room with both residents [Resident 1 and Resident 2] when the other resident [Resident 2] needed to use the restroom; therefore, she [CNA 1] reported to a different CNA [CNA 3] who was also in the dining room that she was leaving to take the other resident [Resident 2] to the restroom. Minutes later [Resident 1] was found on the ground in the dining room. Later in the evening during rounds. [Resident 1] had bruising [discoloration] to the right cheek area and swelling. send [Resident 1] to the ER [Emergency Room] for evaluation [7/22/23]. [Resident 1] returned [7/23/23] from the ER with diagnosis: . Non-displaced [bone cracks or breaks but retains its proper alignment] fracture of the right inferior orbital wall.
During a review of Resident 1's Computed Tomography (CT - imaging technique used to obtain detailed internal images of the body) scan dated 7/23/23, the CT result indicated, fracture of the right inferior orbital wall.
During an interview on 8/2/23 at 9:30 a.m. with Director of Nurses (DON), DON stated on 7/22/23 (at approximately 4:30 p.m.), Resident 1 and Resident 2 were in the dining room with their assigned 2 to 1 sitter (CNA 1) when Resident 2 wanted to get up. DON stated CNA 1 told another staff (CNA 3) who was in the dining room to keep an eye on Resident 1 while CNA 1 took Resident 2 for a walk. DON stated CNA 1 returned (no time given) in the dining room and found Resident 1 on the floor. DON stated Resident 1 was transferred to an acute hospital and sustained a right inferior orbital wall fracture.
During an interview on 8/2/23 at 10 a.m. with CNA 1, CNA 1 stated on 7/22/23, she was assigned as 2 to 1 sitter for Resident 1 and Resident 2 during her p.m. (2 pm-10 pm) shift. CNA 1 stated at approximately 4 p.m. (7/22/23), she was in the dining room with Resident 1 and Resident 2 when Resident 2 needed to use the bathroom. CNA 1 stated before leaving the dining room, she told CNA 3 who was in the dining room passing out snacks, to keep an eye on Resident 1. CNA 1 stated she was not in the dining room when Resident 1 fell on the floor. CNA 1 stated Resident 1 was a fall risk and requiring 2 to 1 sitter at all times to prevent Resident 1 from falling. CNA 1 stated Resident 1's fall incident could have been prevented if someone was watching her [Resident 1].
During a concurrent observation and interview on 8/2/23 at 11:06 a.m. in Resident 1's room, Resident 1 was lying in bed. Resident 1 was observed spitting on the left side of the bed, she did not make an eye contact or respond when spoken to.
During an interview on 8/2/23 at 6:53 p.m. with Licensed Vocational Nurse (LVN), LVN stated on 7/22/23, at approximately 4:30 p.m., CNA 2 found Resident 1 on the floor in the dining room, without staff present. LVN stated a few hours after the fall incident at approximately 8 p.m. Resident 1 started showing a bruise to her face area and was transferred to an acute hospital. LVN stated Resident 1 sustained a right inferior orbital wall fracture. LVN stated Resident 1 was a high risk for fall and was assigned a 2 to 1 sitter to prevent her [Resident 1] from falling. LVN stated the fall could have been prevented if the 2 to 1 sitter was there with her [Resident 1].
During an interview on 8/7/23 at 12:51 p.m. with CNA 3, CNA 3 stated on 7/22/23, she was in the dining room obtaining weights for the residents scheduled to be weigh and she was never asked by CNA 1 to keep an eye on Resident 1. CNA 3 stated there were approximately 15 residents in the dining room doing activities with the Activity Assistant (AS) including Resident 1. CNA 3 stated she was not in the dining room when Resident 1 fell on the floor. CNA 3 stated Resident 1's fall incident could have been prevented if the assigned 2 to 1 sitter was present.
During an interview on 8/9/23 at 2:54 p.m. with AS, AS stated on 7/22/23, at approximately 4:15 p.m., she was in the dining room providing activities for approximately 15 residents including Resident 1. AS stated she noticed Resident 1 sitting in her wheelchair, before leaving the dining room for about 10 minutes for a bathroom break. AS stated nobody had asked her to keep an eye on Resident 1. AS stated she was not in the dining room when Resident 1 fell on the floor.
During an interview on 8/10/23 at 9:30 a.m. with CNA 2, CNA 2 stated on 7/22/23, at approximately 4:30 p.m., she was in the hallway when she heard yelling coming from the dining room. CNA 2 stated she arrived in the dining room and found Resident 1 on the floor next to her wheelchair. CNA 2 stated No other staff were present, no sitter, no activity staff, no CNA's, no RNA's [Restorative Nursing Assistant], there was nobody. CNA 2 stated Resident 1 Had a history of falling and was assigned a 2 to 1 sitter to prevent Resident 1 from falling. CNA 2 stated Resident 1 should not have been left alone, she was screaming pretty loud.
During a concurrent interview and record review on 8/15/23 at 10:52 a.m. with DON, Resident 1's Fall Risk Evaluation (FRE), dated 7/14/23, was reviewed. The FRE indicated, Resident 1 had a score of 11 (if the total score is 10 or greater, the resident should be considered HIGH RISK for potential falls). DON stated [Resident 1] was high risk for fall, was impulsive [tendency to act without thinking], had poor safety awareness and required 2 to 1 sitter.
During a concurrent interview and record review on 8/18/23 at 11:39 a.m. with DON, the facility's daily staff assignment, dated 7/22/23, was reviewed. The daily staff assignment for p.m. shift (2 pm-10 pm) indicated, CNA 1 was assigned as 2 to 1 sitter for Resident 1 and Resident 2. DON stated [Resident 1] should not have been in the dining room without her assigned 2 to 1 sitter.
During a concurrent interview and record review on 9/6/23 at 12 p.m. with DON, DON stated Resident 1 had fall incidents on 5/27/23 and 7/14/23. Resident 1's Care Plan (CP), dated 5/30/23 was reviewed. The CP indicated, Resident 1 was At risk for unavoidable falls related to: Poor safety awareness, Unaware of physical limitations, Impulsiveness, Wanders into other residents room, At times unbalanced on feet. Intervention indicated, Resident 1 to have a 2 to 1 staff at all times. DON stated Resident 1's care plan dated 5/30/23, was not implemented.
During a review of the facility's policy and procedure (P&P) titled, Comprehensive Care Plans, dated 6/1/2022, the P&P indicated, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment.
During a review of the facility's Job Description for (Sitter), undated, the Job Description for sitter indicated, The primary purpose of your job position is to provide close observation of the resident you are assigned to. It is your responsibility to monitor the resident for safety issues and are to keep the resident within arm's length on your entire shift.
During a review of the facility's P&P titled, Accidents and Supervision, dated 2022, the P&P indicated, 3. Implementation of Intervention-using specific interventions to try to reduce a resident's risks from hazards in the environment. The process includes: . e. Ensuring that the interventions are put into action. 5. Supervision is an intervention and a means of mitigating accident risk. The facility will provide adequate supervision to prevent accidents.

Based on observation, interview, and record review, the facility failed to implement one of three sampled residents (Resident 1) Resident to Resident Care Plan (CP). This failure resulted in Resident 1 being left alone without staff supervision for approximately 11 minutes and potential for altercation with other residents.
Findings
During an interview on 7/24/23 at 1 p.m. with Director of Nurses (DON), DON stated on 7/21/23, Resident 1 was involved in a physical altercation with Resident 2. DON stated, Resident 1 was placed on 1 to 1 supervision (one staff to one resident direct observation) to prevent further altercation.
During a concurrent observation and interview on 7/24/23 at 2:09 p.m. with Certified Nursing Assistant (CNA) 1 in Resident 1's room, Resident 1 was lying in bed with her eyes closed. A black steel folding chair was noted next to Resident 1's bed. CNA 1 stated the chair was for the assigned 1 to 1 for Resident 1. CNA 1 stated the assigned 1 to 1 should not have left Resident 1 in her room by herself. CNA 1 excused herself from Resident 1's room to find the assigned 1 to 1.
During a concurrent observation and interview on 7/24/23 at 2:20 p.m. in Resident 1's room, CNA 2 was observed walking into Resident 1's room (approximately 11 minutes after Resident 1 was found in the room by herself). CNA 2 stated she was currently assigned 1 to 1 with Resident 1. CNA 2 stated Resident 1 required to be on 1 to 1 because she goes, and she bothers residents and start fighting. CNA 2 stated she had left Resident 1 alone in her room to use the restroom.
During an interview on 7/24/23 at 2:27 with DON, DON stated it was the facility practice to communicate with other staff members when the assigned 1 to 1 needed to leave the resident to use the restroom, or go on a break. DON stated the assigned 1 to 1 for Resident 1 should not have left Resident 1 alone in her room.
During a review of Resident 1's CP dated 7/21/23, the CP indicated, Resident 1 had a physical altercation with Resident 2. Intervention included, 1 to 1 on day shift and PM shift.
During a review of the facility's policy and procedure (P&P) titled, Comprehensive Care Plans, dated 6/1/22, the P&P indicated, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide supervision for one of three sampled residents (Resident 1) when Resident 1 was not in staff's line of sight (where staff can observe at all times) while up in her wheelchair. This failure resulted in Resident 1 and Resident 2 having a resident-to-resident altercation and Resident 2 falling to the floor, sustaining a right hip fracture (broken bone) requiring hospitalization and the need for surgical intervention.
Findings:
During a review of the Report of Suspected Dependent Adult/Elder Abuse (SOC 341-form used to report suspected abuse) dated 6/8/23, completed by the facility, the SOC 341 indicated, Writer call to Resident [Resident 1] room by nursing staff, per CNA [certified nursing assistant], 'Walked in room [X], near doorway. [Resident 2] was sitting on floor. [Resident 1] was sitting in her wheelchair and had [Resident 2] by the hair and kicked [Resident 2] in the leg [right] as CNA separated them [Resident 1] stated, 'You better stop taking my things.'
During a review of Resident 1's (aggressor) Progress Note (PN), dated, 5/8/23 (one month prior to current incident [6/8/23]), at 9:32 a.m., the PN indicated, IDT [Interdisciplinary Team-group of professionals who work together to discuss about resident care needs] .On 5/8/23 at approx. [approximately] 1:30 pm, staff member reported she witnessed [Resident 1] in dinning [sic] room in her w/c [wheelchair]. There was a female [Resident 4] standing beside [Resident 1], when [Resident 1] stood up from her w/c and reached over to the female resident and with a closed fistmade [sic] contact to the female residents left arm.[Resident 1] is very territorial (guard or defend belongings) with her space and does not like confused (mentally impaired) residents approaching her space.IDT REC [recommendation].keep in line of sight when up in w/c.
During a review of Resident 1's Care plan (CP-specific care needs of resident), dated 5/8/23 (one month prior to current incident [6/8/23]), the CP indicated, [Resident 1] had a resident-to-resident incident where she made contact with another female [Resident 4] left arm.Interventions.continue to be in the line of sight of staff when up in wheelchair.
During a review of Resident 1'sCare plan revised on 5/8/23 (one month prior to current incident [6/8/23]), the CP indicated, Behaviors: [NAME] others off [showing anger or frustration toward a person] at random.Cursing at others.H/O [history of] striking out at others.Unprovoked physical aggression [hostile]/striking out.likes her space and doesnt [sic] like others approaching her.interventions.Keep in line of sight when up in w/c.
During a review of Resident 1's Minimum Data Set (MDS-resident assessment tool), dated 4/21/23, the MDS indicated, BIMS [Brief Interview for Mental Status) Summary Score.4 (0-7 suggests severe impairment).
During a review of Resident 1's Order Summary Report (OSR), dated 6/1/23, the OSR indicated, Resident 1 diagnoses included schizophrenia (a mental condition involving breakdown in the relation between thought, emotion, and behavior, leading to faulty perception, inappropriate actions and feelings, withdrawal from reality and personal relationships into fantasy and delusion, and a sense of mental fragmentation).unspecified dementia (progressive or persistent loss of intellectual functioning especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), psychotic disturbance (severe mental disorders that cause abnormal thinking and perceptions), and anxiety (mental condition characterized by excessive apprehensiveness about real or perceived threats) and Resident 1 was being treated with bupropion (medication used to treat depression).buspirone (medication used to treat anxiety) for behaviors of unprovoked physical aggression.
During a review of Resident 2's (victim) Progress Notes (PN), dated 6/8/23, at 7:30 a.m., the PN indicated, Writer call [sic] to resident room by nursing staff, per CNA, 'walked in room [X], near doorway. [Resident 1] was sitting in her wheelchair and had [Resident 2] by the hair and kicked [Resident 2] in the leg [right] as CNA separated them. 'Per CNA, '[Resident 1] stated, 'you better stop taking my things.'
During a review of Resident 2's PN, dated 6/8/23, at 3 p.m., the PN indicated, Resident complain of pain to right hip area.received order for: X-ray to right hip.
During a review of Resident 2's PN, dated, 6/8/23, at 4:56 p.m., Received order from [Physician] to send resident to ER [Emergency Room] for evaluation due to increase c/o [complaint of] pain.
During a review of Resident 2's Orthopedic (branch of medicine dealing with the correction of deformities of bones or muscles) Consultation (OC), from the acute hospital, dated 6/9/23, the CN indicated, .female who came to the hospital because of after a GLF [ground level fall] at [Facility Name].the patient had an altercation with another resident at [Facility Name] causing her to fall. Impression: Fracture of the right femoral neck (fracture of the right femur [thigh bone] within the hip joint).
During a review of Resident 2's PN, from the acute hospital, dated 6/10/23, at 1:19 p.m., the PN indicated, Assessment/Plans.Fracture of femoral neck, right, closed.underwent right hip hemiarthroplasty [replacing half of the hip joint].
During a review of Resident 2's Order Summary Report (OSR), dated 6/1/23, the OSR indicated, Resident 2 diagnoses included psychotic disturbance (progressive or persistent loss of intellectual functioning especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), and anxiety.
During a review of Resident 2's MDS dated [DATE], the MDS indicated, BIMS Summary Score.00 (0-7 suggests severe impairment).
During an interview, on 6/12/23, at 11:14 a.m., with CNA 1, CNA 1 stated, on the day of the incident (6/8/23), it was Resident 1's first day of being off one-to-one (having a staff member always assigned only to the resident) supervision. CNA 1 stated, she and CNA 2 got Resident 1 up in her wheelchair prior to breakfast. CNA 1 stated, she and CNA 2 were passing breakfast trays and heard Resident 1 speaking loudly. CNA 1 stated, when she arrived in Resident 1's room, she noted Resident 1 sitting in her wheelchair and Resident 2 was sitting on the floor. CNA 1 stated, CNA 2 was in-between Resident 1 and Resident 2, and Resident 1 was swinging at Resident 2. CNA 1 stated, Resident 1 was saying curse words and Resident 2 was saying Resident 1 kicked her on the right side of the leg, and she could not walk anymore. CNA 1 stated, Resident 1 used to have one-to-one supervision due to her aggressive behavior like hitting. CNA 1 stated, she was unaware of any interventions being implemented to prevent further resident-to-resident altercations after the one-to-one supervision was discontinued.
During an interview, on 6/12/23, at 11:41 a.m., with Director of Nursing (DON), DON stated, when Resident 1 was asked regarding the resident-to-resident altercation happened on 6/8/23, Resident 1 verbalized Resident 2 was in my things. DON stated, Resident 1 had just been taken off one-to-one supervision the day (6/7/23) prior to the incident due to Resident 1 not having any resident-to-resident altercations. DON stated, Resident 1 was previously on one-to-one supervision due to incidents of resident-to-resident altercations with other residents. DON stated, Resident 1 had episodes of aggressive behaviors like hitting when someone was in her space.
During an interview on 6/26/23, at 2:11 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, she was assigned to Resident 1 the day (6/8/23) of the resident-to-resident altercation between Resident 1 and Resident 2. LVN 1 stated, Resident 1 had been taken off one-to-one supervision the day (6/7/23) prior to the incident and there was no witness to the resident-to-resident altercation between Resident 1 and Resident 2, on 6/8/23. LVN 1 stated, Resident 1 was previously on one-to-one supervision due to her aggressive behaviors of hitting residents, but she was unaware of any other interventions implemented to prevent further resident-to-resident altercations after the one-to-one supervision was discontinued.
During an interview on 6/26/23, at 2:24 p.m., with CNA 3, CNA 3 stated, Resident 1 would get physically and verbally aggressive with other residents and the facility would try to avoid resident-to-resident altercations by placing Resident 1 on one-to-one supervision. CNA 3 stated, she was unaware of any other interventions implemented to prevent further resident-to-resident altercations after the one-to-one supervision was discontinued.
During an interview on 6/26/23, at 4:27 p.m., with Hospitality Aide (HA) 1 stated, she had been one-to-one supervision with Resident 1 in the past to prevent Resident 1 from getting into physical fights and arguments with other residents.
During an interview on 6/26/23, at 4:41 p.m., with HA 2, HA 2 stated, Resident 1 had been one-to-one supervision because when other residents would go by or even look at Resident 1, Resident 1 would become verbally or physically aggressive.
During an interview on 6/30/23, at 1:13 p.m., with CNA 2, CNA 2 stated, she was assigned to Resident 1 on the day of the resident-to- resident altercation (6/8/23) between Resident 1 and Resident 2. CNA 2 stated, Resident 1 was in her room, sitting in her wheelchair when CNA 2 went to go check on the breakfast trays. CNA 2 stated, she heard someone speaking loudly and went back to Resident 1's room. When she returned to Resident 1's room, Resident 2 was sitting on the floor and Resident 1 had Resident 2 by the hair and was shaking Resident 2's head. CNA 2 stated, when she was separating Resident 1 and Resident 2, Resident 1 kicked Resident 2 on the right side of the leg. CNA 2 stated, no one was watching Resident 1 at the time of the resident-to-resident altercation because Resident 1 was taken off (6/7/23) one-to-one supervision. CNA 2 stated, any small thing can trigger [Resident 1's behavior] her or if someone is in her way and she will start fighting. CNA 2 stated, she was unaware of any other interventions being implemented to prevent further resident-to-resident altercations.
During an interview on 6/30/23, at 1:25 p.m., with DON, DON stated, no one witnessed the resident-to-resident altercation (6/8/23) between Resident 1 and Resident 2. DON stated, Resident 1 does not like to stay in her room when she is up in her wheelchair she should have been where staff could see her at all times according to the care plan.
During a review of the facility's policy and procedure (P&P) titled, Care Plan Revisions Upon Status Change dated 6/1/22, with the DON, on 7/26/23 at 11:37 a.m., the P&P indicated, The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change.Upon identification of a change in status, the nurse will notify the MDS (minimum data set-resident assessment tool) Coordinator, the physician, and the resident representative.The MDS Coordinator and the Interdisciplinary Team will discuss the resident condition and collaborate on intervention options.The team meeting discussion will be documented in the nursing progress notes.The care plan will be updated with the new or modified interventions.Staff involved in the care of the resident will report resident responses to new or modified interventions. DON stated, staff should have been made aware of Resident 1's care plan interventions.

Based on interview and record review, the facility failed to ensure the front entrance was locked and supervision was provided for one of three sampled residents (Resident 1) with a diagnosis of dementia (symptoms that includes forgetfulness, limited social skills, and impaired thinking skills that interferes with daily functioning). This failure resulted in Resident 1 eloping from the facility without staff being aware and potential for harm.
Findings:
During a review of Resident 1's Progress Note (PN), dated 5/20/23, at 2:03 p.m., the PN indicated, Elopement, [Resident 1] observed outside the building in the parking lot by staff.
During an interview on 5/31/21, at 12:45 p.m., with Certified Nursing Assistant (CNA 1), CNA 1 stated, on 5/20/23, a visitor (Hospice Nurse-HN) had asked her to open the front entrance/exit door to let her (HN) out of the facility. CNA 1 stated, while opening the door, she noticed Resident 1 standing near the front entrance/exit door. CNA 1 stated, she called Resident 1 by her name, while proceeding to walked back to another hall where she (CNA 1) continued with her assignment. CNA 1 stated, it was not within her job description to open doors for visitors. CNA 1 stated, she did not pay attention whether the front door entrance/exit was completely closed and locked after opening the door for the visitor. CNA 1 stated, Resident 1 had a diagnosis of dementia, and it was not safe for Resident 1 to go outside by herself without supervision.
During an interview on 5/31/23, at 1:08 p.m. with Director of Nurses (DON), DON stated, Resident 1 had a history of elopement. DON stated, when opening any of the facility doors, staff should ensure no resident is near the door before opening and always make sure the door is completely closed and locked.
During an interview on 5/31/23, at 3:09 p.m., with HN, HN stated, on 5/20/23, a staff member (CNA 1) opened the door for her to exit the facility. HN stated, she was unaware Resident 1 followed her outside the building until after she was seated in her car, looked up and saw several staff running towards Resident 1. HN stated, I really think she [Resident 1] slipped out.
During an interview on 6/12/23, at 11:27 a.m. with CNA 2, CNA 2 stated, on 5/20/23, he was outside sitting in his car when he noticed HN walking out of the facility. CNA 2 stated, within a few minutes later, he noticed Resident 1 walking outside the facility following the HN. CNA 2 stated, no other staff was following Resident 1. CNA 2 stated, Resident 1 may have exited the facility because the door was not locked. CNA 2 stated, Sometimes the door [front door entrance/exit] doesn't lock, you have to wait for the door to click in place.
During a review of Resident 1's Minimum Data Set (MDS-a standardized, comprehensive assessment tool), dated 3/16/23, the MDS indicated, Resident 1's had a BIMS (Brief Interview for Mental Status-which evaluates cognition, the ability to remember and think clearly) score of 3 (score of 0-7 severely impaired cognition).
During a review of Resident 1's Comprehensive Care Plan (CCP), dated 12/30/22, the CCP indicated, Resident 1 was At risk for elopement related to: Attempts to leave Living Center, Resident states I am leaving, going home , Wandering.
During a review of the facility's policy and procedure (P&P) titled, Elopement and Wandering Residents, dated 6/1/22, the P&P indicated, This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person centered plan of care addressing the unique factors contributing to wandering or elopement risk. Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so.

Based on interview and record review, the facility failed to develop a comprehensive care plans for two of 16 sampled residents (Resident 32 and Resident 5 ) when:
1. Resident 32 had a limitation in range of motion (ROM) to his lower extremities.
2. Resident 5 had a physicians' order (PO) for passive range of motion (PROM) to her bilateral lower extremities (BLE).
These failures had the potential to result in staff being unaware of residents' needs and Resident 32 and Resident 5 not getting required treatments.
Findings:
1. During a concurrent observation and interview on 5/24/21, at 11:45 AM, with Certified Nursing Assistant (CNA ) 4, in the hallway near Resident 32's room, Resident 32 was observed sitting in his wheelchair. CNA 4 stated, Resident 32 has limitation in range of motion to his lower extremities.
During a review of Resident 32's Quarterly Minimum Data Set (MDS - a standardized assessment tool), dated 3/21/21, the MDS indicated, Section G Functional Status. Functional Limitation in Range of Motion . Impairment on both sides. B. Lower extremity (hip, knee, ankle, foot).
During a concurrent interview and record review, on 5/27/21, at 11:23 AM, with Minimum Data Set Nurse (MDSN), Resident 32's care plan was reviewed. MDSN stated, Resident 32 was receiving services from the Physical Therapist and Occupational Therapist from 1/6/21 to 3/16/21. MDSN was unable to find a care plan to address his limitation in ROM to his lower extremities. MDSN stated, a care plan should have been initiated to address Resident 32's limitation in ROM to his lower extremities.
2. During a review of the PO dated 5/13/21, the PO, indicated Resident 5 was to receive PROM to her lower extremities every Tuesday, Thursday, and Saturday.
During a concurrent interview and record review on 5/27/21, at 11:52 AM, with the Director of Nursing (DON), DON reviewed the clinical record for Resident 5. The DON was unable to produce a care plan for restorative care for Resident 5. The DON stated, Resident 5 should have a care plan for restorative care.
During a review of the facility's policy and procedure (P&P) titled Restorative Nursing Services, revised 7/17, the P&P indicated, Residents will receive restorative nursing care as needed to help promote optimal safety and independence. 1. Restorative nursing care consists of nursing interventions that may or may not be accompanied by formalized rehabilitative services . 3. Restorative goals and objectives are individualized and resident-centered, are outlined in the resident's plan of care.
During a review of the facility's P&P titled, Care Planning-Interdisciplinary Team, revised 9/13, the P&P indicated, 1. A comprehensive care plan for each resident is developed within seven (7) days of completion of the resident assessment (MDS).

Based on observation, interview, and record review, the facility failed to provide food that accommodates resident's preferences and allergies for two of 16 sampled residents (Resident 21 and Resident 54) when:
1. Resident 21, with a lactose intolerance allergy, was being served house nourishments, which contain milk, four times a day .
2. Resident 54 was served two of her food dislikes for lunch.
These failures had the potential to result in inadequate intake and possible weight loss for Resident 21 and Resident 54.
Findings:
1. During an interview on 5/26/21, at 11:11 AM, with Family Member (FM) 1, FM 1 stated, [Resident 21] is Lactose intolerant. It gives her digestive issues.
During a review of Resident 21's Order Summary Report (OSR), dated May 2021, the OSR indicated, allergies: Lactose Intolerant. Regular diet, add HN [house nourishment] to all meals. Sugar free house nourishment two times a day between meals.
During a review of Resident 21's Care Plan (CP), dated 1/5/20, the CP indicated, Nutrition: [Resident 21] is also Lactose intolerant. Will not serve foods/drinks which contain Lactose.
During a concurrent observation and interview on 5/26/21, at 11:45 AM, with Certified Dietary Manager (CDM), in the kitchen, a house nourishment was taken out of the refrigerator and the label indicated, Nonfat Milk. This was verified by the CDM. CDM stated, she was unaware Resident 21 had a Lactose allergy and confirmed she gets these house nourishments four times a day.
During an observation on 5/26/21, at 12 PM, in Resident 21's room, she was served lunch with 4 oz (ounces- unit of measure) of milk and 4 oz of house nourishment. Resident 21's diet card did not indicate lactose allergy.
During a review of the facility's policy and procedure (P&P) titled, Food Allergies and Intolerances, dated August 2017, the P&P indicated, 5. Residents with food Intolerances and allergies are offered appropriate substitutions for foods that they cannot eat.
2. During an observation on 5/26/21, at 12:20 PM, in Resident 54's room, Resident 54 was observed not eating her lunch. On her plate, she had roast beef, sweet potatoes, zucchini and carrots. Her diet card indicated, Dislikes: carrots and yams.
During a concurrent observation and interview on 5/26/21, at 12:38 PM, with CDM, in Resident 54's room, CDM verified Resident 54 had carrots and sweet potatoes on her plate and verified these were listed as dislikes on her diet card.
During a review of the facility's P&P titled, Food Preferences, dated 2018, the P&P indicated, Resident's food preferences will be adhered to within reason. Substitutes for all foods disliked will be given from the appropriate food group.

Based on observation, interview, and record review, the facility failed to ensure breakfast was served at a preferred time for one of 16 sampled residents (Resident 21). This failure had the potential to result in weight loss and inadequate meal intake.
Findings:
During an interview on 5/26/21, at 11:11 AM, with Family Member (FM) 1, FM 1 stated, Resident 21 likes to eat breakfast late morning because she does not get up early.
During a review of Resident 21's Order Summary Report (OSR), dated May 2021, the OSR indicated, Dietary-Diet: Breakfast @ 0900.
During a review of Resident 21's Care Plan (CP), dated 1/5/20, the CP indicated, Nutrition: Move Breakfast to 0900.
During a concurrent observation and interview on 5/25/21, at 9:14 AM, with Certified Nursing Assistant (CNA) 3, Resident 21 did not receive a breakfast tray at 9 AM. CNA 3 stated, Resident 21 is served breakfast the same time as all the other residents.
During an interview on 5/26/21, at 11:45 AM, with Certified Dietary Manager (CDM), CDM stated, Resident 21 is served breakfast the same time as all the other residents. CDM stated, she is unaware of her preferring breakfast at 9 AM.
During an interview on 5/26/21, at 3:06 PM, with Registered Dietician (RD) 2, RD 2 stated, the staff member who makes the care plan that indicates a resident wants a meal at a certain time will communicate with the dietary staff to get the tray to that resident at their preferred time.
During a review of the facility's policy and procedure (P&P) titled, Meal Service, dated 2018, the P&P indicated, Resident preferences for meal times & food temperatures shall be honored.

Based on interview and record review, the facility failed to maintain an accurate and complete medical record for one of 16 sampled residents (Resident 48) for his G-Tube (gastrostomy tube - a tube inserted surgically through the abdomen into the stomach for nutrition and medications) bolus feeding (a type of feeding method using a syringe to deliver formula through the G-Tube). This failure had the potential for Resident 48 not to receive the appropriate bolus feeding via G-Tube as ordered by the physician.
Findings:
During a concurrent interview and record review on 5/26/21, at 3:55 PM, with Director of Nursing (DON), Resident 48's Medication Administration Record (MAR), dated May 2021 was reviewed. The MAR indicated, Tube Feed Bolus Feeding of Glucerna (a nutritional supplement for people with diabetes) 1.2 [calories] one can/carton {237 ml - milliliter [a unit of measurement) TID [three times a day] if po [by mouth intake] is <75% [less than 75 percent]. The check marks indicated, Chart Codes / Follow Up Codes. [check mark] = Administered. The MAR had check marks on the following dates and times when Resident 48 was eating 75% or more which indicated G-Tube Bolus Feeding of Glucerna was Administered to Resident 48.
5/2/21- Meal %: 9 AM - 100%; 1 PM - 100%.
5/3/21- Meal %: 9 AM - 100%; 6 PM - 100%.
5/4/21 - Meal %: 9 AM - 75%; 1 PM - 75%.
5/5/21 - Meal %: 1 PM - 75%; 1 PM - 75%; 6 PM - 75%.
5/6/21 - Meal %: 6 PM - 75%.
5/7/21 - Meal %: 9 AM - 100%.
5/9/21 - Meal %: 9 AM - 100%.
5/10/21 - Meal %: 9 AM - 75%; 1 PM - 75%.
5/11/21 - Meal %: 9 AM - 75%; 1 PM - 75%.
5/12/21 - Meal %: 9 AM - 100%; 1 PM - 75%; 6 PM - 75%.
5/13/21 - Meal %: 6 PM - 75%.
5/14/21 - Meal %: 9 AM - 100%; 1 PM - 75%, 6 PM - 75%.
5/15/21 - Meal %: 6 PM - 75%.
5/16/21 - Meal %: 9 AM - 75%; 6 PM - 75%.
5/17/21 - Meal %: 9 AM - 100%; 1 PM - 75%6 PM - 75%.
5/18/21 - Meal %: 9 AM - 75%; 1 PM - 75%; 6 PM 75%.
5/19/21 - Meal %: 1 PM - 75%.
5/20/21 - Meal %: 9 AM - 9 AM - 75%; 1 PM - 75%.
5/21/21 - Meal %: 9 AM - 100%.
5/22/21 - Meal %: 9 AM - 75%.
5/23/21 - Meal %; 9 AM - 75%.
5/24/21 - Meal %: 9 AM - 100%; 1 PM - 75%; 6 PM - 100%.
DON stated, Resident 48's G-Tube Bolus Feeding of Glucerna was not accurately documented by the staff. DON stated, Glucerna should not be checked as administered [if eating 75% or more of his oral intake]. DON stated, It should have been documented as 7 - Other / See Nurse Notes as indicated in the Chart Codes / Follow Up Codes, in the MAR.

Based on observation, interview, and record review, the facility failed to ensure an item on the menu was prepared and served to 34 of 34 residents (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 8, Resident 9, Resident 12, Resident 13, Resident 16, Resident 18, Resident 21, Resident 23, Resident 24, Resident 26, Resident 28, Resident 29, Resident 32, Resident 34, Resident 35, Resident 37, Resident 39, Resident 40, Resident 41, Resident 42, Resident 44, Resident 45, Resident 51, Resident 52, Resident 55, Resident 58, Resident 59, Resident 60, and Resident 61) on a therapeutic diet. This failure had the potential to alter texture and nutritional value for these residents.
Findings:
During a review of the lunch menu, dated 5/25/21, the menu indicated, Roast Turkey, Cranberry-Ginger-Citrus Sauce, Gravy, Bread Dressing, Seasoned Peas, Three Bean Salad, Vanilla Mousse Chocolate Chip Garnish, and Milk.
During a concurrent observation and interview on 5/25/21, at 11:28 AM, with [NAME] 2, in the kitchen, tray line (process of preparing residents meal trays) was observed. Only one sauce was noted on the steam table. [NAME] 2 stated, it was cranberry-ginger-citrus sauce. [NAME] 2 was asked where the gravy was; [NAME] 2 stated, sauce and gravy are the same thing and there was not a separate gravy.
During a concurrent observation and interview on 5/25/21, at 11:30 AM, with Certified Dietary Manager (CDM), in the kitchen. CDM verified the menu for the day and stated, there should be gravy served for the residents on a mechanical soft (food that is soft in texture) diet, pureed (foods with a pudding-like consistency) diet, the dysphagia mechanical (foods that are soft and moist) diet and the CCHO (controlled carbohydrates) diet.
During an interview on 5/25/21, at 12:23 PM, with Registered Dietician (RD) 1, RD 1 stated, gravy is different than sauce on the menu and certain therapeutic diets needed the gravy instead of the sauce.
During a review of the facility's policy and procedure (P&P) titled, Menu Planning, dated 2020, the P&P indicated, 4. The menus are planned to meet nutritional needs of residents in accordance with established national guidelines, physician's orders and, to the extent medical possible . Procedures: 1. The facilities' diet manual and the diets ordered by the physician should mirror the nutritional care provided by the facility. 2. Menus are written for regular and modified diets in compliance with the diet manual.

Based on observation, interview, and record review, the facility failed to:
1. Ensure the prefilled syringes (single-dose packet syringes) of Morphine Sulfate (medication used to treat moderate to severe pain) were labeled with expiration dates for two of 16 sampled residents (Resident 1 and Resident 31). This failure had the potential to result in residents receiving expired medications.
2. Remove a medication for one time use only from the medication cart for one of 16 sampled residents (Resident 47). This failure had the potential for medication errors.
3. Remove discontinued medication from the medicine cart for one of 16 Residents (Resident 37). This failure had the potential to contribute to adverse consequences to the residents.
Findings:
1. During a concurrent observation and interview on 5/25/2, at 9:35 AM, with Licensed Vocational Nurse (LVN) 2, in the Central Supply Room, prefilled Morphine Sulfate syringes for the following residents were found stored, locked and kept inside the medication cart with no expiration dates:
a. Resident 31 - 20 prefilled syringes of 0.25 ml (milliliter - a unit of measurement) of Morphine Sulfate 100 mg/ml (milligram - a unit of measurement) were not labeled with expiration dates.
b. Resident 1 - 26 prefilled syringes of 0.5 ml of Morphine Sulfate 100 mg/ml were not labeled with expiration dates.
LVN 2 stated, I don't see expiration dates [on the Morphine Sulfate prefilled syringes]. I'll take it to the DON [Director of Nursing]. LVN 2 stated, the prefilled syringes of Morphine Sulfate should have been labeled with expiration dates.
During a review of the facility's policy and procedure (P&P) titled, Medication Ordering And Receiving From Pharmacy, dated 4/14, the P&P indicated, Medications are labeled in accordance with facility requirements and state and federal laws. B. Each prescription label includes:.8) Expiration date of medication. G. Medication containers having. incomplete. labels are returned to the dispensing pharmacy for relabeling or destroyed in accordance with the medication destruction policy.
2. During a concurrent observation and interview on 5/25/21, at 9:15 AM, with LVN 2, in the Central Supply Room, one used bottle of Potassium Chloride (medication used to treat or prevent low potassium in the blood) 40 mEq (milliequivalants - a unit of measurement)/15 ml for Resident 47 was found labeled for one time use only. LVN 2 stated, it should have been removed from the medication cart and discarded after it was administered to Resident 47. 3. During a concurrent observation and interview on 5/25/21, at 8:36 AM, LVN 1 was observed preparing medication for administration for Resident 37 in room. LVN 1 took out Metoprolol (a medication used for high blood pressure [BP]) 25 milligrams (mg-a unit of measurement) pill pack (PP-a packet that contains a resident's specific medication) from her medication cart. Prior to giving Resident 37 her medication she took Resident 37's BP, which was 102/50. LVN 1 stated, I will hold this medication, her BP is low and it is not within the parameters.
During a review of Resident 37's Order Summary (OS), dated 5/25/21, the OS did not indicate a physician's order for Metoprolol medication.
During a concurrent interview and record review on 5/25/21, at 3:11 PM, with LVN 1, Resident 37's OS dated 5/25/21 was reviewed. LVN 1 stated, she could not find the MD medication order for Metoprolol. She stated, it was my error I pulled out the Metropolol by accident. LVN 1 stated, the medication was discontinued. LVN 1 was asked if the Metropolol medication PP should still have been in her medication cart, and she stated, No, it should have been taken out.
During an interview on 5/27/21, at 8:25 AM, with DON, DON stated, the discontinued medication should not be kept in the medication cart, it should be discarded and destroyed.
During a review of the facility's P&P titled, Administering Medications, dated 4/19, the P&P indicated, Medication are administered in a safe and timely manner, and as prescribed . The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.
During a review of the facility's P&P titled, Disposal of Medications and Medication related supplies, dated 12/18, the P&P indicated, When medications are expired, discontinued by a prescriber, a resident is transferred or discharged and does not take medication with him/her, or in the event of a resident's death, the medications are marked as discontinued or stored in a separate location and later destroyed. Discontinued medications are destroyed in accordance with the Medication Destruction policy.

Based on observation, interview, and record review, the facility failed to ensure two of 16 sampled residents (Resident 5 and Resident 21) received restorative care. This failure had the potential to result in decreased safety and independence for Resident 5 and Resident 21.
Findings:
During a review of Resident 5's physicians orders (PO), dated 5/13/21, the PO indicated Resident 5 was to receive passive range of motion (PROM) to her lower extremities every Tuesday, Thursday, and Saturday.
During a concurrent interview and record review on 5/27/21, at 9:14 AM, with the Director of Nursing (DON), DON reviewed the Restorative Record dated 5/21 for Resident 5. DON confirmed multiple dates with no documentation (5/1/21, 5/4/21, 5/11/21, 5/18/21, and 5/20/21). DON stated, If it is not documented it is not done.
During an observation on 5/24/21, at 12:15 PM, in Resident 21's room, Resident 21 was lying in bed with a food tray in front of her.
During an observation on 5/26/21, at 12 PM, in Resident 21's room, Resident 21 was lying in bed with a food tray in front of her.
During a review of Resident 21's Order Summary Report (OSR), dated 4/9/21, the OSR indicated, RNA (Restorative Nursing Assistance) Program: 3 x/week for 90 days. Assist patient up in wheelchair for lunch and dinner every Monday, Wednesday, and Friday.
During an interview on 5/26/21, at 5:19 PM, with Clinical Resource Consultant (CRC), CRC stated, there is no documentation for this RNA program. CRC stated This was a silly order because our CNA's [Certified Nursing Assistants] are capable of doing this. The order should have been discontinued and it wasn't
During a review of the facility's policy and procedure (P&P) titled, Restorative Nursing Services, dated July 2017, the P&P indicated, Residents will receive restorative nursing care as needed to help promote optimal safety and independence.

Based on observation, interview, and record review, the facility failed to ensure two of 16 sampled residents (Resident 32 and Resident 44) were assisted with grooming. These failures had the potential for the residents not to maintain their highest practicable level of functioning and well-being.
Findings:
1. During a concurrent observation and interview on 5/25/21, at 3:18 PM, with Certified Nursing Assistant (CNA) 5, in Resident 44's room, Resident 44 was observed to have long fingernails with black colored debris underneath all his fingernails. CNA 5 stated, Resident 44 was unable to perform his personal hygiene and required assistance to clean and trim his fingernails. CNA 5 stated, Resident 44 should have been assisted by staff in cleaning and trimming his fingernails.
2. During a concurrent observation and interview on 5/25/21, at 3:24 PM, with CNA 5, in Resident 32's room, Resident 32 was observed to have long fingernails with black colored debris underneath all his fingernails. CNA 5 stated, the fingernails needed to be trimmed and cleaned.
During a review of Resident 32's Quarterly Minimum Data Set (MDS - a standardized assessment tool), dated 3/21/21, the MDS indicated, Section G. Functional Status. J. Personal hygiene. 2 [limited assistance with personal hygiene].
During a review of the facility's policy and procedure (P&P) titled, Activities of Daily Living (ADL), Supporting, dated 3/18, the P&P indicated, Resident will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain. grooming, and personal. hygiene.

Based on observation, interview, and record review, the facility failed to ensure 15 Ready Care shakes were stored at the proper temperature prior to being served to residents. This failure had the potential to cause foodborne illnesses for facility's residents.
Findings:
During a concurrent observation and interview on 5/25/21, at 8:40 AM, with Dietary Aide (DA) 2, in the kitchen, 15 Ready Care Shakes were observed sitting on a cart in a plastic bin. DA 2 stated, the shakes were for the snack cart and staff would be picking up the cart between 9:45 AM -10 AM. DA 2 did not know at what temperature the shakes were supposed to be served.
During a concurrent observation and interview on 5/25/21, at 9:15 AM, with DA 2 and the Certified Dietary Manager (CDM), in the kitchen, DA 2 was adding ice to the plastic bin with the 15 Ready Care Shakes. One shake was removed and DA 2 checked the temperature of the liquid inside the carton. The temperature read 60 degrees Fahrenheit (F) (unit of measurement). CDM verified this finding and stated, the shakes are not supposed to sit out of the refrigerator for 30 minutes and should be served to the resident at 41 degrees F or below. CDM verified the carton label indicated, keep refrigerated.
During a review of the facility's policy and procedure (P&P) titled, Meal Service, dated 2018, the P&P indicated, Recommended Temp [temperature] at Delivery to Resident: Milk/Cold Beverage less than or equal to 45 degrees F.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 12) responsible party (RP) was properly notified of Medicare benefit changes. This failure had the potential for Residents 12's RP to not make an informed decision regarding Medicare services.
Findings:
During a concurrent interview and record review on 5/26/21, at 3:49 PM, with Minimum Data Set Nurse (MDSN), MDSN stated, the MDSNs were responsible for completing the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNFABN -form used to inform residents and RP of their potential financial liability and appeal rights and protections should they wish to receive care and services that may not be covered by Medicare). MDSN confirmed, that there was no documentation on the SNFABN for Resident 12 dated 1/4/2020 and 12/4/2020 in the areas titled Care, Reason Medicare may not pay:, or the Estimated Cost. She stated, option 3 was selected (I don't want the care listed above. I understand that I'm not responsible for paying, and I can't appeal to see if Medicare would pay) was selected but nothing is listed above she could not speak to what the RP was agreeing to. MDSN stated, the SNFABN should have been completed.
During a review of the facility's policy and procedure (P&P) untitled, undated, the P&P indicated, IV. SNF ABN CMS 10055 - .b. MDS with SSD will also provide beneficiary/responsible party when there are skilled benefit days remaining and determined that the beneficiary no longer meets requirements for skilled level of care and resident continues to stay in the facility. d. Ensures that all areas are complete and signed.