Coalinga Regional Medical Ctr Dp/Snf

Based on interview and record review, the facility failed to maintain complete and accurate documentation and follow its policy and procedures titled Falls - Clinical Protocol and Charting and Documentation for two of six sampled residents (Resident 1 and Resident 2), when the Licensed Vocational Nurse (LVN) 1 did not complete the neuro-check (a focused assessment of the nervous system used to identify acute changes in an individual's functional status) on 11/17/25 and 11/18/25 for Resident 1 after an unwitnessed fall on 11/15/25, and the Director of Nursing (DON) did not complete IDT (Interdisciplinary Team; a group of staff members consisting of physicians, nursing, dietary, rehabilitation, social services, activities, and administration who meet regularly to discuss incidents that occurred involving the well-being of residents and staff) note for Resident 2 on 12/18/25 after an unwitnessed fall on 12/17/25. These failures had the potential to result in the delayed detection of neurological changes which could lead to irreversible functional impairment for Resident 1 after an unwitnessed fall on 11/15/25 and the potential for the IDT to miss opportunities to discuss, intervene, and care plan for Resident 2 after an unwitnessed fall on 12/17/25.Findings: During a record review of Resident 1's admission Record, dated 2/17/26, the AR indicated Resident 1 had a diagnosis of Type 2 Diabetes Mellitus (a chronic metabolic disorder where the body develops insulin resistance resulting in high blood sugar level), Osteomyelitis of the right ankle and foot (an infection and inflammation of the bone or bone marrow), Chronic Obstructive Pulmonary Disease (a progressive lung condition characterized by chronic respiratory symptoms and persistent irreversible airflow limitation), and Chronic Heart Failure (a long-term, progressive clinical syndrome where the heart muscle is too weak or stiff to pump sufficient blood throughout the body). During a record review of Resident 1's Minimum Data Set (MDS; process for clinical assessment of all residents of long term care nursing facilities), dated 1/23/26, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS; an assessment of a resident's cognitive (mental process) status; the ability to remember, concentrate, learn new things, and/or make decisions that affect their everyday life) score was 12 out of 15 (a score of 0 to 7 indicated severe impairment, 8 to 12 indicated moderate impairment, and 13 to 15 indicated minimal to no impairment) which indicated Resident 1 had moderate cognitive impairment. During a record review of Resident 1's SBAR ([Situation, Background, Appearance, Review] Communication Form; a communication tool licensed staff use to share pertinent information with the resident's physician and responsible party when there is a change in the resident's condition), dated 11/15/25, the SBAR indicated, .Primary Care Clinician Notified: Yes. Date: 11/15/25. Time: 11:25 a.m. Recommendations of Primary Clinicians: Send to ER (Emergency Room) for scan of head and right shoulder. During a record review of Resident 1's Progress Notes (PN), dated 11/15/25, the PN indicated, Writer was called to the dining room by Certified Nursing Assistant (CNA), resident was sitting on the floor next to wheelchair. Resident stated she stood up to get coffee and slid to the floor landing on bottom then falling sideways hitting her right shoulder and head. notified [name of primary care physician] got order to send to ER for evaluation. During a concurrent interview and record review on 2/17/26 at 9:52 a.m. with the DON, Resident 1's Neuro Checklist (NC), dated 11/15/25 was reviewed. The NC indicated, Interval: Every 30 min. X2 (every 30 minutes two times an hour), Every 1 hour X3, Every 2 hours X24 hours, Every 4 hours X5, Every 8 hours (for 24 hours). The NC indicated the initial V/S (Vital Signs-blood pressure, Temperature, Pulse, Respiration), Level of Consciousness, Right Pupil, Left Pupil, Right Hand Grip, Left Hand Grip, and Nurse Initial was not completed for 11/17/25 and 11/18/25. The DON stated LVN 1 was assigned to Resident 1 on 11/17/25 and 11/18/25 and LVN 1 should have completed the NC for 11/17/25 and 11/18/25 to indicate that Resident 1's neurological status was assessed. The DON stated that a delay in recognizing early neurological changes could delay the management of a serious neurological problem which could lead to serious negative outcomes such as permanent impaired cognition (mental process), speech, function and mobility. The DON stated medical records should be complete and accurate to reflect the care provided. During a record review of Resident 2's AR, dated 2/11/26, the AR indicated Resident 2 had a diagnosis of Alzheimer's Disease (a chronic, progressive, and irreversible neurodegenerative brain disorder that slowly destroys memory, thinking skills, and the ability to perform simple daily tasks), and Dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking). During a record review of Resident 2's MDS, dated 12/31/25, the MDS indicated, Resident 2's BIMS score was 2 out of 15 which indicated Resident 2 had severe cognitive impairment. During a record review of Resident 2's SBAR, dated 12/17/25, the SBAR indicated, .Primary Care Clinician Notified: Yes. Date: 12/17/25. Time: 3:00 a.m. Recommendations of Primary Clinicians: Notified MD of unwitnessed fall, implemented neuro checks, monitor for delay injuries, one time order CT (Computed Tomography; a medical imaging procedure that uses X-rays and computer technology to create detailed cross-sectional of the body used to visualize bones, blood vessels, and soft tissues) of the head. During a record review of Resident 2's Progress Notes (PN), dated 12/17/25, the PN indicated, Writer was notified by CNA that resident had unwitnessed fall in the bathroom. Resident walked to the bathroom and lost his balance. Small abrasion noted on left big toe. Order for CT of the head place. During a concurrent interview and record review on 2/11/26 at 11:49 a.m. with the DON, Resident 2's IDT Post Incident Meeting (IDT), dated 12/18/25 was reviewed. The IDT indicated, .A. IDT Meeting. 1. Date & Time: 12/18/25 4:18 p.m. The remainder of the record was not completed. The DON stated the IDT note should have been completed to indicate the IDT met to discuss Resident 2's fall, the cause of the fall, interventions to prevent the fall from recurring, who was notified and acknowledge any new orders. The DON stated she should have completed the IDT note and did not. During an interview on 2/11/26 at 11:49 a.m. with the Medical Record Director (MRD), the MRD stated residents' medical records should be complete and accurate to reflect the care provided. The MRD stated partially completed or incomplete documentation of records indicated the service was not provided. During an interview on 2/18/25 at 10:03 a.m. with the Administrator (ADM), the ADM stated the facility was required to maintain complete and accurate documentation of records to reflect the care provided for the residents. The ADM stated the neuro-check was required to be completed to ensure the resident received the proper level of care. The ADM stated the IDT note was required to be completed after an incident to ensure the resident was aligned with the appropriate care plan and the IDT did not miss anything. The ADM stated the IDT was made up of leadership individuals from different departments (nursing, rehabilitation, social services, etc.) to collaborate and provide holistic care (a comprehensive approach to health that treats the whole person which includes physical, emotional, mental, social, and spiritual rather than just symptoms or a specific disease) for the residents. The ADM stated an in-service (education and training) will be provided for the staff, so all departments would be aware of documentation requirements. The ADM stated an in-service will be provided to leadership staff who participate in the IDT to document the importance of the meeting to coordinate care for residents. During a review of the facility's policy and procedure (P&P) titled, Falls - Clinical Protocol, dated 9/2012, the P&P indicated, Assessment and Recognition: 1. As part of the initial assessment, the physician will help identify individuals with a history of falls and risk factors for subsequent falling. 7. Falls should also be identified as witnessed or unwitnessed events. Cause Identification: 1. For an individual who has fallen, staff will attempt to define possible causes within 24 hours of the fall. Treatment/Management: 1. Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling. Monitoring and Follow-Up: 1. The staff, with the physician's guidance, will follow up on any fall with associated injury until the resident is stable and delayed complications such as late fracture or subdural hematoma (a dangerous, often life-threatening collection of blood that gathers between the brain's surface and its outer covering) have been ruled out or resolved. 2. The staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling. 5. As needed, the physician will document the presence of uncorrectable risk factors, including reasons why any additional search for causes is unlikely to be helpful. During a review of the facility's P&P titled, Charting and Documentation, dated 4/2008, the P&P indicated, Policy Statement: All services provide to the resident, or any changes in the resident's medical or mental condition, shall be documented 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 follow its policy and procedure (P&P) titled Charting and Documentation in accordance with professional standards of practice for one of three sampled residents (Resident 2), when the certified nursing assistants (CNA) did not document Resident 1's urine output every shift on 10/31/25, 11/1/25, 11/2/25, 11/5/25, 11/9/25, 11/10/25, 11/12/25. This failure had the potential to result in delay in care and cause an infection from not assisting Resident 2 with urine elimination.Findings:During a review of Resident 2's admission Record (AR- a summary of information regarding a resident which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated, Resident 2 was admitted to the facility on [DATE] with diagnosis for cerebral infarction (blocked or reduced blood supply to the brain), calculus of kidney (hard piece of material that form in one or both kidneys), muscle weakness, constipation. During a review of Resident 2's Minimum Data Set [MDS a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment] dated 7/9/2025, the MDS indicated, Resident 2's Brief Interview for Mental Status (BIMS screening tool used to assess resident cognitive level) score was 8 out of 15 (0 - 7 indicated severe cognitive impairment [memory loss, poor decision making skills] 8-12 moderate cognitive impairment, (13 -15) cognitively intact) which indicated Resident 2 had moderate cognitive impairment. During a review of Resident 2's, Bladder Elimination Record, dated 10/31/25-11/12/25, the bladder elimination record indicated Resident 2 had been assisted with urination on: 10/31/25- 5:04 a.m. Amount four times for the day, 11/1/25- 3:26 a.m. amount three times for the day, 11/2/25 5:05 a.m. amount five times for the day, 11/3/25- 4:56 a.m. four times & 5:41 p.m. four times, 11/4/25- 5:59 a.m. amount six times & 5:04 p.m. amount four times, 11/5/25- 5:59 a.m. amount six times for the day, 11/6/25- 5:53 a.m. amount four times & 2:26 p.m. amount three times, 11/7/25- 5:18 a.m. amount five times & 4:49 p.m. four times, 11/8/25- 5:59 a.m. amount six times for the day, 11/9/25- 5:59 a.m. amount six times for the day, 11/10/25- 5:59 a.m. amount six times & 8:50 a.m. five times, 11/11/25- 5:57 a.m. five times & 5:17 p.m. five times, 11/12/25- 5:59 a.m. two times for the day. During a concurrent interview and record review on 11/12/25 at 10:51 a.m. with Licensed vocational nurse (LVN) 3, Resident 2's, Bladder Elimination record, dated 10/31/25-11/12/25, was reviewed. LVN 3 stated the bladder elimination record was completed by the certified nursing assistants (CNA) who were caring for Resident 2. LVN 3 stated the expectation was for the CNAs to document the number of times Resident 2 was assisted during the working shift with urine elimination. LVN 3 stated the bladder elimination record was incomplete, as some of the CNA entries were not completed for the days of 10/31/25, 11/1/25, 11/2/25, 11/5/25, 11/9/25, 11/10/25, 11/12/25. LVN 3 stated the incomplete documentation on the bladder elimination record indicated the care did not occur because it was not accurately documented. LVN 3 stated it was important that CNAs complete all documentation timely and accurately to ensure Residents are monitored appropriately when voiding. LVN 3 stated the CNA documentation was an important part of all residents' care and services provided. During a concurrent interview and record review on 11/12/25 at 1:07 p.m. with the director of nursing (DON), Resident 2's, Bladder Elimination record, dated 10/31/25-11/12/25, was reviewed. The DON stated the expectation was for the CNAs to complete all documentation for all residents before they leave the facility at the end of the shift. The DON stated CNAs were expected to document after each time a resident was assisted to the bathroom, not just at the end of the shift. The DON stated it was important to have complete and accurate documentation to monitor and treat residents as needed. During a review of the facility's policy and procedure (P&P) titled, Charting and Documentation, dated 7/2017, the P&P indicated, . All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Documentation in the medical record may be electronic, manual or a combination. The following information is to be documented in the resident medical record. Treatments or services performed. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. During a review of a professional reference from the American Nurses Association titled, Principles for Nursing Documentation, dates 2010, the reference indicated, . Clear, accurate, and accessible documentation is an essential element of safe, quality, evidence-based nursing practice. Documentation of nurses' work is critical as well for effective communication with each other and with other disciplines. It is how nurses create a record of their services for use by payors, the legal system, government agencies, accrediting bodies, researchers, and other groups and individuals directly or indirectly involved with health care. It also provides a basis for demonstrating and understanding nursing's contributions both to patient care outcomes and to the viability and effectiveness of the organizations that provide and support quality patient care. Entries into organization documents or the health record (including but not limited to provider orders) must be Accurate, valid, and complete, Authenticated; that is, the information is truthful, the author is identified, and nothing has been added or inserted, Dated and time-stamped by the persons who created the entry.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation interview and record review the facility failed to follow its policy and procedure (P&P) titled Charting and Documentation in accordance with professional standards of practice for one of three sampled residents (Resident 1), when the licensed nurses did not change Resident 1's wound dressing every shift as ordered by the physician for two days and documented in the electronic medical record that the wound treatment was completed. This failure had the potential to result in delay in care, wound healing, and cause an infection from bacteria buildup.Findings:During a review of Resident 1's admission Record (AR- a summary of information regarding a resident which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnosis for injury at C5 level of cervical spinal cord (damage to the nerves in the neck that control muscles in the upper body), Stage 4 pressure ulcer (Stage 1: The skin is intact but looks red, and may feel warm, firm, or painful. Stage 2: The skin breaks, creating a shallow open sore or a ruptured blister. Stage 3: The sore deepens into a crater that reaches the layer of fat beneath the skin. Stage 4: The damage extends through the skin to the muscle, bone, or joints, open wound with exposed bone). During a review of Resident 1's Minimum Data Set [MDS a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment] dated 11/11/2025, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS screening tool used to assess resident cognitive level) score was 15 out of 15 (0 - 7 indicated severe cognitive impairment [memory loss, poor decision making skills] 8-12 moderate cognitive impairment, (13 -15) cognitively intact) which indicated Resident 1 was cognitively intact. During an interview on 11/12/25 at 12:01 p.m. with Resident 1 in his room, Resident 1 stated he had a wound to the coccyx (small bone at the bottom of the spine) that required wound dressing change every day. Resident 1 stated there were days when the nurses would not complete his treatment as ordered by the physician. Resident 1 stated the last time the wound dressing was changed was on 11/9/25. Resident 1 stated he had requested the nurse to change his dressing for the past two days but was unsuccessful. Resident 1 stated he felt neglected by the facility nurses when he would request the wound dressing be changed and the nurses did not complete the treatment order. During a concurrent observation and interview on 11/12/25 at 12:12 p.m. with licensed vocational nurse (LVN) 1, Resident 1's wound dressing and wound to the coccyx were observed. The wound dressing was observed initialed and dated 11/9/25. LVN 1 stated that according to the date on the wound dressing, Resident 1's wound dressing was last changed on 11/9/25. During a record review of Resident 1's, Order Summary Report, dated 10/13/25, the order summary indicated, . Coccyx pressure ulcer stage 4- Cleanse with wound cleaner, pat dry, pack loosely with gauze w/ [brand name medication], cover foam dressing. As needed. Coccyx pressure ulcer stage 4- Cleanse with wound Phone cleaner, pat dry, pack loosely with gauze w/ [brand name medication], cover foam dressing. Every shift. The order summary indicated Resident 1 had a physician order for routine wound dressing changes every shift, everyday and as needed in between. During a record review of Resident 1's, Treatment Administration Record (TAR), dated 11/2025, the TAR indicated, . Coccyx pressure ulcer stage 4- Cleanse with wound Phone cleaner, pat dry, pack loosely with gauze w/ [brand name medication], cover foam dressing. Every shift. The TAR indicated, Resident 1's treatment order was signed as completed on 11/9/25, 11/10/25, and 11/11/25. During an interview and record review on 11/12/25 at 12:20 p.m. with LVN 1, Resident 1's, Order Summary Report, dated 10/13/25 and Resident 1's, Treatment Administration Record (TAR), dated 11/2025, were reviewed. The order summary indicated, . Coccyx pressure ulcer stage 4- Cleanse with wound cleaner, pat dry, pack loosely with gauze w/ [brand name medication], cover foam dressing. As needed. Coccyx pressure ulcer stage 4- Cleanse with wound Phone cleaner, pat dry, pack loosely with gauze w/ [brand name medication], cover foam dressing. Every shift. The TAR indicated, . Coccyx pressure ulcer stage 4- Cleanse with wound Phone cleaner, pat dry, pack loosely with gauze w/ [brand name medication], cover foam dressing. Every shift. LVN 1 stated the TAR indicated the wound dressing treatment order was completed on 11/9/25, 11/10/25, and 11/11/25 but based on the concurrent wound dressing observation, the last date on the wound dressing was 11/9/25. LVN 1 stated the facility process was for the nurse to complete the treatment order from the physician and to initial and date the wound dressing to validate the wound dressing was changed. LVN 1 stated it was important to initial and date the wound dressing to ensure the wound dressing was changed as ordered. LVN 1 stated, documentation on the TAR was false, because observed dressing on Resident 1's coccyx did not match with the TAR. LVN 1 stated it was important to complete and document all wound treatment as orders to prevent a wound infection. During an interview on 11/12/25 at 12:30 p.m. with LVN 2, LVN 2 stated the facility process was to complete all Resident treatment orders. LVN 2 stated the facility process included initialing and dating the wound dressing to ensure the dressings were being changed. LVN 2 stated it was important to complete all treatment orders to prevent infections and to prevent wound deterioration. During an interview on 11/12/25 at 12:54 p.m. with the registered nurse supervisor (RNS), the RNS stated the facility expectation was for the wound dressing to have been completed as ordered by the physician. The RNS stated the facility process was to initial and date the dressing being applied to the wound to ensure the dressing was changed. The RNS stated if a wound dressing could not be completed during a shift, the facility nurse is expected to document it and endorse the treatment to another nurse and let the RNS know. During an interview on 11/12/25 at 1:07 p.m. with the director of nursing (DON), the DON stated the expectation was for the treatment order to be completed for every resident. The DON stated the expectation was for the nurse to notify the RNS when a wound treatment could not be completed. The DON stated it was not acceptable to document a wound treatment was completed when the wound dressing was not changed. The DON stated it was important to have complete and accurate documentation to monitor and treat the wounds as needed. During a review of the facility's policy and procedure (P&P) titled, Charting and Documentation, dated 7/2017, the P&P indicated, . All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Documentation in the medical record may be electronic, manual or a combination. The following information is to be documented in the resident medical record. Treatments or services performed. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. During a review of a professional reference from the American Nurses Association titled, Principles for Nursing Documentation, dates 2010, the reference indicated, . Clear, accurate, and accessible documentation is an essential element of safe, quality, evidence-based nursing practice. Documentation of nurses' work is critical as well for effective communication with each other and with other disciplines. It is how nurses create a record of their services for use by payors, the legal system, government agencies, accrediting bodies, researchers, and other groups and individuals directly or indirectly involved with health care. It also provides a basis for demonstrating and understanding nursing's contributions both to patient care outcomes and to the viability and effectiveness of the organizations that provide and support quality patient care. Entries into organization documents or the health record (including but not limited to provider orders) must be Accurate, valid, and complete, Authenticated; that is, the information is truthful, the author is identified, and nothing has been added or inserted, Dated and time-stamped by the persons who created the entry.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to follow facility's policies and procedures and meet professional standards of quality for one of three sampled Residents (Resident 1), when staff did not document Resident 1's change of condition (COC) or Situation, Background, Assessment and Recommendation communication form (SBAR- communication tool that provides critical information and ensures that important details are clearly communicated) for a staff to resident allegation of abuse on 7/13/25.This failure had the potential to result in the inaccurate assessment of Resident 1, delay in care and was at risk for further abuse.Findings:During a review of Resident 1's admission Record (AR- a summary of information regarding a resident which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnosis for Anxiety (excessive worry and fear), expressive language disorder (condition that affects a person's ability to use language, both written and spoken), dysphasia (disorder that affects the ability to understand, produce or use language). During a review of Resident 1's Minimum Data Set [MDS a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment] dated 3/3/2025, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS screening tool used to assess resident cognitive level) score was 0 out of 15 (0 - 7 indicated severe cognitive impairment [memory loss, poor decision making skills] 8-12 moderate cognitive impairment, (13 -15) cognitively intact) which indicated Resident 1 had severe cognitive impairment.During a review of Resident 2's, Nurse's Note, dated 7/15/25, the note indicated, . [Resident 2] reported that on Sunday 7/13/25 [Resident 1] was in a foul mood and was walking outside because that's what he likes to do. Later he went outside to smoke, and [AA 2] was real upset with [Resident 1] because he would not go inside earlier and when it came time to put on the smoking vest [AA 2] approached [Resident 1], who was reportedly sitting down on the bench, and very sharply shoved the vest into [Resident 1] chest, you could hear the thump. [Resident 1] stood up and got into a fighting stance and for the first time ever I heard [Resident 1] speak. [Resident 2] then stated that [AA 2] replied with try to touch me, if you do, you'll go to prison for assaulting a healthcare worker. [Resident 2] reported that she did not know exactly what [Resident 1] had said, because Resident 1 did not speak most of the time and when he does you cannot understand him, but she recalls [AA 2] response. After [AA 2] had made that statement [Resident 1] reportedly turned around, put his cigarette out, which he never does, he always finishes it and went back inside. [Resident 1] did not go back outside the rest of the shift until [AA 2] went home for the night. [Resident 2] reports feeling safe in the facility.During a review of Resident 2's admission Record, the AR indicated, Resident 2 was admitted to the facility on [DATE] with diagnosis for Anxiety (excessive worry and fear).During a review of Resident 1's Minimum Data Set, dated [DATE], the MDS indicated Resident 2's Brief Interview for Mental Status score was 15 out of 15 which indicated Resident 2 was cognitively intact.During an interview on 7/17/25 at 11:28 a.m. with licensed vocational nurse (LVN) 1, LVN 1 stated the facility process was to complete a COC for any change in resident health status. LVN 1 stated there should have been a COC completed for the alleged staff to resident abuse incident. LVN 1 stated the purpose of the COC was to accurately document what had occurred and to communicate it through the electronic medical record (EMR). During a concurrent interview and record review on 7/17/25 at 12:20 p.m. with interim director of nurses (IDON), Resident 1's electronic medical record (EMR) was reviewed. The IDON stated the EMR indicated there was no COC completed for Resident 1's allegation of staff to resident abuse that occurred on 7/13/25. The IDON stated it was important to ensure all documentation was completed for Resident 1's incident of abuse, to monitor Resident 1 for changes in health status and well-being.During a concurrent interview and record review with the interim administrator (IADM), the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status, dated 2001, was reviewed. The P&P indicated, . A significant change of condition is a major decline or improvement in the resident's status that will not normally solve itself without intervention by staff. required interdisciplinary review and/or revision to the care plan. the nurse will make detailed observation and gather relevant and pertinent information for the provider, including information prompted by the SBAR . The IADM stated there should have been a COC completed for any resident changes in health status and for the staff to resident abuse incident with Resident 1.During a review of a professional reference from the American Nurses Association titled, Principles for Nursing Documentation, dates 2010, the reference indicated, . Clear, accurate, and accessible documentation is an essential element of safe, quality, evidence-based nursing practice. Documentation of nurses' work is critical as well for effective communication with each other and with other disciplines. It is how nurses create a record of their services for use by payors, the legal system, government agencies, accrediting bodies, researchers, and other groups and individuals directly or indirectly involved with health care. It also provides a basis for demonstrating and understanding nursing's contributions both to patient care outcomes and to the viability and effectiveness of the organizations that provide and support quality patient care. Entries into organization documents or the health record (including but not limited to provider orders) must be Accurate, valid, and complete, Authenticated; that is, the information is truthful, the author is identified, and nothing has been added or inserted, Dated and time-stamped by the persons who created the entry.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents were free from abuse for one of four sampled residents (Resident 1), when on 7/13/25 the activity assistant (AA) 2 was physically and verbally aggressive toward Resident 1 during the smoking break.This failure resulted in verbal and physical abuse toward Resident 1 and placed Resident 1 in an unsafe living environment.Findings:During a review of Resident 1's admission Record (AR- a summary of information regarding a resident which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnosis for Anxiety (excessive worry and fear), expressive language disorder (condition that affects a person's ability to use language, both written and spoken), dysphasia (disorder that affects the ability to understand, produce or use language).During a review of Resident 1's Minimum Data Set [MDS a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment] dated 3/3/2025, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS screening tool used to assess resident cognitive level) score was 0 out of 15 (0 - 7 indicated severe cognitive impairment [memory loss, poor decision making skills] 8-12 moderate cognitive impairment, (13 -15) cognitively intact) which indicated Resident 1 had severe cognitive impairment.During an interview on 10/17/25 at 10:05 a.m. with the interim administrator (IADM), the IADM stated she had received a report on 7/15/25 from Resident 3, stating she had witnessed a AA 2 hitting Resident 1 with a clothing protector during the smoke break and yelling at Resident 1 on 7/13/25. The IADM stated the facility initiated an investigation that revealed Resident 2 and Resident 3 were both witnesses to the incident. The IADM stated the allegation was found to be substantiated and AA 2 was suspended pending termination.During a review of Resident 3's admission Record, the AR indicated Resident 3 was admitted to the facility on [DATE] with diagnosis for Anxiety (excessive worry and fear).During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3's BIMS score was 14 out of 15 which indicated Resident 3 was cognitively intact.During a concurrent observation and interview on 7/17/25 at 10:39 a.m. with Resident 1 and Resident 3, both residents were observed outside during their smoke break. Resident 3 stated on 7/13/25, Resident 1, Resident 2 and Resident 3 were outside preparing for a smoke break accompanied by AA 2. Resident 3 stated AA 2 approached Resident 1 with the clothes protector used while smoking. Resident 3 stated AA 2 placed Resident 1's clothing protector with enough force to hear a thump from Resident 1's chest. Resident 1 observed moving his head to indicate yes in agreement. Resident 3 stated, Resident 1 reacted by standing up in front of AA 2, then AA 2 was heard raising his voice stating, Hit me so I can put you in jail for hitting a healthcare worker. Resident 3 stated Resident 1 had not reacted even though AA 2 tried to provoke and instigate a fight. Resident 1 observed moving his head to indicate yes in agreement.During a review of Resident 2's admission Record, the AR indicated, Resident 2 was admitted to the facility on [DATE] with diagnosis for Anxiety (excessive worry and fear).During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2's BIMS score was 15 out of 15 which indicated Resident 2 was cognitively intact.During a review of Resident 2's, Nurse's Note, dated 7/15/25, the note indicated, . [Resident 2] reported that on Sunday 7/13/25 [Resident 1] was in a foul mood and was walking outside because that's what he likes to do. Later he went outside to smoke, and [AA 2] was real upset with [Resident 1] because he would not go inside earlier and when it came time to put on the smoking vest [AA 2] approached [Resident 1], who was reportedly sitting down on the bench, and very sharply shoved the vest into [Resident 1] chest, you could hear the thump. [Resident 1] stood up and got into a fighting stance and for the first time ever I heard [Resident 1] speak. [Resident 2] then stated that [AA 2] replied with try to touch me, if you do, you'll go to prison for assaulting a healthcare worker. [Resident 2] reported that she did not know exactly what [Resident 1] had said, because Resident 1 did not speak most of the time and when he does you cannot understand him, but she recalls [AA 2] response. After [AA 2] had made that statement [Resident 1] reportedly turned around, put his cigarette out, which he never does, he always finishes it and went back inside. [Resident 1] did not go back outside the rest of the shift until [AA 2] went home for the night. [Resident 2] reports feeling safe in the facility.During an interview on 7/17/25 at 10:47 a.m. with Resident 2, Resident 2 stated that on 7/13/25, Resident 1, Resident 2 and Resident 3 were outside preparing for a smoke break accompanied by AA 2. Resident 2 stated AA 2 approached Resident 1 with the clothes protector used while smoking. Resident 2 stated AA 2 placed Resident 1's clothing protector with enough force to hear a thump from Resident 1's chest. Resident 2 stated, Resident 1 reacted by standing up in front of AA 2, then AA 2 was heard in a volatile voice stating, Hit me I dare you so I can put you in jail for hitting a healthcare worker. Resident 2 stated Resident 1 took off his clothing protector and turned off his cigarette and proceeded to walk inside not reacting to the incident.During an interview on 7/17/25 at 11:00 a.m. with AA 1, AA 1 stated Resident 3 had reported that on 7/13/25, an incident had occurred with Resident 1 and AA 2. AA 1 stated Resident 3 reported AA 2 was aggressive and yelling toward Resident 1 during their smoking break. AA 1 stated, Resident 3 reported AA 2 was instigating a fight with Resident 1, telling him to Hit him so he can go to jail for hitting a healthcare worker. AA 1 stated the incident was verbal abuse and the facility process was to attempt to de-escalate resident behavior and ensure safety.During an interview on 7/17/25 at 11:22 a.m. with certified nursing assistant (CNA) 1, CNA 1 stated the incident that had occurred on 7/13/25 between AA 2 and Resident 1 was a form of abuse. CNA 1 stated when AA 2 escalated the situation by yelling and instigating a fight, he placed Resident 1 in an unsafe environment.During a telephone interview on 7/24/25 at 3:10 p.m. with AA 2, AA 2 stated he was the AA on 7/13/25. AA 2 stated he recalled an incident in which Resident 1 had stood up suddenly when AA 2 went to put on the clothing protector. AA 2 stated, Resident 1 looked as if he was going to hit him because Resident 1 took a step toward AA 2 and puffed his chest. AA 2 stated he stepped backward and immediately went to alert LVN 1 and informed LVN 1 that Resident 1 was threatening to hit him. AA 2 stated, LVN 1 had responded by stating, tell him if he hit you he would go to jail for hitting a healthcare worker. AA 2 stated he then went back outside and told Resident 1 what LVN 1 had stated. AA 2 stated Resident 1 continued to walk toward AA 2 as AA 2 walked backwards. AA 2 stated after the incident, Resident 1 took off the clothing protector and threw his cigarette on the floor. AA 2 stated, he did not feel it was verbal abuse because he was simply relaying the message that LVN 1 told him to de-escalate the situation by telling Resident 1, he would go to jail.During a review of the facility's policy and procedure (P&P) titled, Recognizing signs and Symptoms of Abuse/Neglect, dated 2011, the P&P indicated, . Abuse is defined as willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Neglect is defined as failure to provide goods and services as necessary to avoid physical harm, mental anguish, or mental illness. Signs of Actual Physical Neglect. Caregiver indifference to resident's personal care and needs.During a review of the facility's P&P titled, Resident Rights, dated 1/2024, the P&P indicated, . Employees shall treat all residents with kindness, respect, and dignity. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a dignified existence, be treated with respect, kindness, and dignity, be free from abuse, neglect, misappropriation of property, and exploitation, be supported by the facility in exercising his or her rights.

Based on interview, facility document review, and facility policy review, the facility failed to ensure a registered nurse (RN) was on duty daily for eight consecutive hours. This deficient practice had the potential to affect all residents who resided in the facility.
Findings included:
A facility policy titled, RN Coverage Policy, last reviewed by the facility on 05/01/2024, revealed the section titled, A. Minimum RN Coverage, included, 1. An RN will be on duty a minimum of 8 consecutive hours per day, 7 days a week.
Facility nursing schedules for the timeframe from 10/01/2024 through 04/07/2025 revealed RN coverage was provided Mondays through Fridays.
A facility nursing schedule for October 2024 indicated there were no RNs scheduled to work on 10/05/2024, 10/06/2024, 10/12/2024, 10/13/2024, 10/19/2024, 10/20/2024, 10/26/2024, and 10/27/2024.
A facility nursing schedule for November 2024 indicated there were no RNs scheduled to work on 11/02/2024, 11/03/2024, 11/09/2024, 11/10/2024, 11/16/2024, 11/17/2024, 11/23/2024, 11/24/2024, and 11/30/2024.
A facility nursing schedule for December 2024 indicated there were no RNs scheduled to work on 12/01/2024, 12/07/2024, 12/08/2024, 12/15/2024, 12/21/2024, 12/22/2024, 12/28/2024 and 12/29/2024.
A facility nursing schedule for January 2025 indicated there were no RN's scheduled to work on 01/01/2025, 01/04/2025, 01/05/2025, 01/11/2025, 01/12/2025, 01/18/2025, 01/19/2025, 01/25/2025 and 01/26/2025.
A facility nursing schedule for February 2025 indicated there were no RNs scheduled to work on 02/01/2025, 02/02/2025, 02/08/2025, 02/09/2025, 02/15/2025, 02/16/2025, 02/22/2025, and 02/23/2025.
A facility nursing schedule for March 2025 indicated there were no RNs scheduled to work on 03/01/2025, 03/02/2025, 03/08/2025, 03/09/2025, 03/15/2025, 03/16/2025, 03/22/2025, 03/23/2025, 03/29/2025, and 03/30/2025.
A facility nursing schedule for April 2025 indicated there were no RNs scheduled to work on 04/05/2025 and 04/06/2025.
During an interview on 04/09/2025 at 9:46 AM, the Director of Nursing (DON) stated she knew the facility was required to have RN coverage at least eight hours every day, and she revealed that from October 2024 to 04/09/2025 they had not had any RN coverage for the weekends.
During an interview on 04/09/2025 at 10:28 AM, the Administrator stated he thought the facility only had to have a nurse scheduled, not necessarily an RN, and the facility did not have an RN scheduled for the weekends.

Based on interview, facility document review, and facility policy review, the facility failed to ensure a registered nurse (RN) was identified on the daily staff posting. This deficient practice had the potential to affect all residents who resided in the facility.
Findings included:
A facility policy titled, Posting of Daily Hours per Patient Day (DHPPD), last reviewed by the facility on 05/01/2024, revealed, The posting shall include: Breakdown of RN, LVN [licensed vocational nurse]/LPN [licensed practical nurse], and CNA [certified nursing assistant] hours
Facility nursing schedules for the timeframe from 10/01/2024 through 04/07/2025 revealed RN coverage was provided Mondays through Fridays.
A facility document titled, Daily Census & NHPPD [Nursing Hours per Patient Day] for the timeframe from 10/01/2024 through 04/07/2025 revealed the daily posted staffing sheets did not identify RN coverage as part of their nursing staff.
During an interview on 04/09/2025 at 4:05 PM, the Staffing Coordinator stated she did not count (document) any RN hours on the daily staffing sheets.
During an interview on 04/10/2025 at 1:52 PM, The Director of Nursing (DON) stated she expected the staff to make sure the daily staffing sheets were accurate.
During an interview on 04/10/2025 at 2:18 PM, the Administrator stated he expected the daily staffing sheets to be accurate and show the staff who worked.

Based on interview, facility document review, and facility policy review, the facility failed to electronically submit the Payroll-Based Journal (PBJ) (staffing information for all employees in the nursing home based on payroll data submitted on a quarterly schedule) to the Centers for Medicare and Medicaid Services (CMS) for one quarter of the 2025 Fiscal Year for the facility.
Findings included:
A facility policy titled, Payroll-Based Journal (PBJ) Reporting Policy, revised 05/01/2024, revealed, [Facility Name] will maintain an accurate and verifiable system for collecting, validating, and submitting staffing and census data to CMS through the PBJ system on a quarterly basis, as required under 42 CFR [Code of Federal Regulations] §[section]483.70(q). The policy revealed the section titled, 5. CMS Submission, included, A confirmation of receipt and validation report will be reviewed and retained.
The facility's PBJ Staffing Data Report for quarter one of fiscal year 2025 revealed the facility did not submit the PBJ report for the first quarter (October 1 - December 31) of fiscal year 2025.
During an interview on 04/10/2025 at 12:40 PM, the Staffing Coordinator stated that the previous Assistant Administrator was responsible for the PBJ submission. The Staffing Coordinator stated she would be trained to do the PBJ submission now because she was responsible for staffing and the hours per patient day (HPPD) reporting.
During an interview on 04/10/2025 at 2:06 PM, the Director of Nursing (DON) stated the Assistant Administrator left the position in late December 2024. The DON stated that when the Assistant Administrator was at the facility, he had been responsible for submitting the PBJ data. The DON stated she was not sure who submitted the PBJ data now. The DON stated she expected the PBJ data to be submitted in a timely manner.
During an interview on 04/10/2025 at 2:31 PM, the Administrator stated he was not able to provide evidence that the first quarter PBJ data was submitted. The Administrator stated it was his expectation that facility staff follow all protocol, policy, and CMS regulations for PBJ data to be submitted timely, and the facility staff should have been doing that.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure accuracy of documentation according to professional standards for three of three sampled residents (Resident 1, Resident 2 and Resident 3), when the assistant director of nurses/minimum data set (ADON/MDS) nurse documented and electronically signed for the social services director (SSD) on 1/3/25 and 1/6/25 in Resident 1, Resident 2 and Resident 3 ' s multidisciplinary care conference (MCC-meeting that could consists of director of nurses, physician, dietary staff, therapy staff, social services, activities, resident and resident representative to discuss resident care) notes.
This failure resulted in falsified documentation and could have caused delay in care resulting from the inaccuracy of the documentation for Resident 1, Resident 2, and Resident 3.
Findings:
During a review of Resident 1's admission Record (AR- a summary of information regarding a resident which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnosis for anxiety (constant worry or feeling afraid), dysphagia (difficulty swallowing) and transient ischemic attack (temporary disruption of blood flow in the brain).
During a review of Resident 1's Minimum Data Set [MDS a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment] dated 2/19/25, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS screening tool used to assess resident cognitive level) score was 11 out of 15 (0 - 7 indicated severe cognitive impairment [memory loss, poor decision making skills] 8-12 moderate cognitive impairment, (13 -15) cognitively intact) which indicated Resident 1 had moderate cognitive impairment.
During a review of Resident 2's AR, the AR indicated, Resident 2 was admitted to the facility on [DATE] with diagnosis for muscle wasting, dysphagia (difficulty swallowing), major depressive disorder (persistent feeling of sadness and loss of interest).
During a review of Resident 2's MDS, dated [DATE], the MDS indicated, Resident 1's BIMS score was 13 out of 15 which indicated Resident 2 was cognitively intact.
During a review of Resident 3's AR, the AR indicated, Resident 3 was admitted to the facility on [DATE] with diagnosis for major depressive disorder (persistent feeling of sadness and loss of interest), cerebral infarction (blood flow is blocked I the brain) and schizoaffective disorder (condition with symptoms of hallucinations, sadness).
During a review of Resident 3's MDS, dated [DATE], the MDS indicated, Resident 3's BIMS score was 14 out of 15 which indicated Resident 2 was cognitively intact.
During an interview on 3/27/25 at 10:31 a.m. with the SSD, the SSD stated there was documentation being falsified in Resident 1 ' s records. The SSD stated there were documents that were signed on behalf of the SSD department, even when the SSD was not physically in the facility. The SSD stated the resident assessments had to be completed thoroughly and accurately because the assessments were regarding residents ' mood and behavior and contributed to the plan of care. The SSD stated the instances were reported to the administration but felt there was retaliation from administrative staff following the report.
During an interview on 3/27/25 at 10:45 a.m. with the licensed vocational nurse (LVN) 1, LVN 1 stated there were instances when LVN 1 was signed as an attendant to resident care conferences or resident assessments but was not in attendance. LVN 1 stated she could not recall the dates or time but had noticed multiple instances in which that had occurred. LVN 1 stated the instances were not reported to the administration for fear of retaliation against LVN 1. LVN 1 stated it was important to have complete and accurate documentation to effectively care for the resident.
During an interview on 3/27/25 at 10:51 a.m. with the ADON/MDS nurse, the ADON/MDS stated the role of the MDS was to ensure documentation was complete and accurate. The ADON/MDS stated if the assessments were found to be incorrect, she would delete the documented portion completed by the other department members and correct it. The ADON/MDS stated she would not notify the department members when the documentation was changed or deleted. The ADON/MDS stated she oversaw documenting during the MCC meetings for residents in the facility. The ADON/MDS stated, the only person she would add as physically attending the care conference meetings was the DON, even when the DON was not physically in the facility. The ADON/MDS stated she had not falsified documentation for any resident.
During an interview on 3/27/25 at 11:24 a.m. with the director of clinical operations (DCO), the DCO stated there was a complaint made by a former employee regarding instances of false documentation, but it was determined the ADON/MDS was completing the documentation to assist the members of the IDT. The DCO stated documentation should have been complete and accurate according to the residents ' assessments and IDT documentation.
During a concurrent interview and record review on 3/27/25 at 11:57 a.m. with the SSD and DON present, Resident 1 ' s, Multidisciplinary Care Conference (MCC), dated 1/6/25, Resident 2 ' s, MCC, dated 1/3/25 and Resident 3 ' s, MCC, dated 1/3/25, were reviewed. Resident 1 ' s MCC indicated, . Attendance at meeting . social worker . Social work summary, orientation status, Resident alert and oriented x3. Resident able to make needs known to staff . Problems/needs, monthly [medical doctor] visit, monthly with [nurse practioner psychiatrist] . discharge goals, long-term care anticipated . Name [social services director electronic signature] . Resident 2 ' s MCC indicated . Attendance at meeting . social worker . Social work summary, orientation status, Resident is alert and oriented. Able to verbalize needs . Problems/needs, monthly with [medical doctor] . discharge goals, long-term care anticipated . Name [social services director electronic signature]. Resident 3 ' s MCC indicated, . Attendance at meeting . social worker . Social work summary, orientation status, Resident alert and oriented. Able to verbalize needs . Problems/needs, monthly with [medical doctor], monthly discharge goals, long-term care anticipated . Name [social services director electronic signature] . The SSD stated she was not present during the MCC meetings for Resident 1, Resident 2 and Resident 3 but documentation showed the SSD was present during the meeting. The SSD stated the MCC was electronically signed and completed when SSD was not present during the conference. The SSD stated each department in the facility oversaw their portion of the MCC and the SSD portion should not have been completed by any other facility department.
During a concurrent interview and record review on 3/27/25 at 12:10 p.m. with the DON and SSD present, Resident 1 ' s, Multidisciplinary Care Conference, dated 1/6/25, Resident 2 ' s, MCC, dated 1/3/25 and Resident 3 ' s, MCC, dated 1/3/25, were reviewed. Resident 1 ' s MCC indicated, . Attendance at meeting . social worker . Social work summary, orientation status, Resident alert and oriented x3. Resident able to make needs known to staff . Problems/needs, monthly [medical doctor] visit, monthly with [nurse practioner psychiatrist] . discharge goals, long-term care anticipated . Name [social services director electronic signature] . Resident 2 ' s MCC indicated . Attendance at meeting . social worker . Social work summary, orientation status, Resident is alert and oriented. Able to verbalize needs . Problems/needs, monthly with [medical doctor] . discharge goals, long-term care anticipated . Name [social services director electronic signature]. Resident 3 ' s MCC indicated, . Attendance at meeting . social worker . Social work summary, orientation status, Resident alert and oriented. Able to verbalize needs . Problems/needs, monthly with [medical doctor], monthly discharge goals, long-term care anticipated . Name [social services director electronic signature] . The DON stated all documentation should have been complete and accurate. The DON stated the purpose of the MCC was to bring all departments together and discuss the needs of the resident and how the residents were progressing. The DON stated it was every departments responsibility to only complete the portion that pertained to their department and to not complete the portion of another department as they would not have the knowledge to accurately reflect the care given. The DON stated when a department was not going to be present for the MCC, it was the expectation that no one would be completing their portion of the conference until they returned to the facility.
During a concurrent telephone interview and record review on 4/3/25 at 11:00 a.m. with the DON, the SSD ' s, Daily Time Report, dated 1/1/25-1/31/25, was reviewed. The DON stated the Report indicated, the SSD did not have documented working hours on 1/3/25 and 1/6/25. The DON stated the SSD was not present in the facility on the dates of the completed MCC ' s for Resident 1, Resident 2 and Resident 3.
During a review of the facility ' s job description titled, ADON/MDS Coordinator, undated, the job description indicated, . The Assistant Director of Nursing (ADON) and MDS Nurse is responsible for assisting in the overall nursing management of the [Facility name] and coordinating the completion of accurate and timely MDS assessments for all residents . Monitor and report on the accuracy and completeness of MDS assessments and related documentation. Provide staff training on MDS processes, documentation, and related procedures .
During a review of a professional reference from the American Nurses Association titled, Principles for Nursing Documentation, dates 2010, the reference indicated, . Clear, accurate, and accessible documentation is an essential element of safe, quality, evidence-based nursing practice . Documentation of nurses ' work is critical as well for effective communication with each other and with other disciplines. It is how nurses create a record of their services for use by payors, the legal system, government agencies, accrediting bodies, researchers, and other groups and individuals directly or indirectly involved with health care. It also provides a basis for demonstrating and understanding nursing ' s contributions both to patient care outcomes and to the viability and effectiveness of the organizations that provide and support quality patient care . Entries into organization documents or the health record (including but not limited to provider orders) must be Accurate, valid, and complete, Authenticated; that is, the information is truthful, the author is identified, and nothing has been added or inserted, Dated and time-stamped by the persons who created the entry .
During a review of the facility ' s policy and procedure (P&P) titled, Documentation Policy, undated, the P&P indicated, . The purpose of this policy is to establish standardized practices for documenting care, treatment and patient progress in the skilled nursing facility (SNF) setting . this policy applies to all healthcare providers . it is the policy of [facility name] that all healthcare providers document patient care accurately, timely, and legibly in the patient ' s medical record. Documentation must be complete . and reflect a true and accurate account of the patient ' s status, treatments, and outcomes . general requirements . accuracy all entries must be accurate and reflect the patient ' s current condition . signature. All entries must be signed and dated by the healthcare provider responsible for the care. For electronic documentation, this may include an electronic signature . corrections. If errors are made, corrections must be made in a way that maintains the integrity of the original entry .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents were free from abuse and neglect for one of three sampled residents (Resident 1), when Resident 1 was left outside for approximately one hour without supervision and the temperature was 92 degrees Fahrenheit on 9/29/24.
This failure resulted in Resident 1's body temperature to reach 101.1 degrees Fahrenheit (normal body temperature range from 97 degrees to 99 degrees Fahrenheit) and elevated heart rate of 136 beats per minute (normal heart rate for adults is between 60-100 beats per minute) and had the potential for Resident 1 to experience heat exhaustion, dehydration and/or sunburn of the skin.
Findings:
During a review of Resident 1's admission Record (a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses of abnormalities of gait (walking) and mobility (movement), respiratory failure, conversion disorders with seizures, pain, and muscle weakness
During a review of Resident 1's Minimum Data Set [MDS a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment] dated 9/10/24, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS screening tool used to assess resident cognitive level) score was 0 out of 15 (0 - 7 indicated severe cognitive impairment [memory loss, poor decision making skills] 8-12 moderate cognitive impairment, (13 -15) cognitively intact) which indicated Resident 1 had severe cognitive impairment.
During an interview on 10/17/24 at 10:25 a.m. with the director of nursing (DON), the DON stated on 9/29/24, Resident 1 was left outside by the activities assistant (AA). The DON stated the facility staff was alerted by the facility housekeeper that Resident 1 was sitting outside in the heat. The DON stated that the AA was immediately sent home, and Resident 1 was assessed for injuries. The DON stated it was the responsibility of the AA to monitor Resident 1 while he was outside and to have brought him back inside the facility when he was done.
During a review of professional reference titled, The Weather Channel, dated 9/29/24, the reference indicated that the outside temperature was recorded at 92 degrees Fahrenheit.
During an interview on 10/17/24 at 10:54 a.m. with the activities director (AD), the AD stated he was notified of the incident involving Resident 1 being left outside by AA. The AD stated the AA should have known that any resident including Resident 1 required consistent monitoring especially when they were outside. The AD stated that when Resident 1 was left outside there was a risk for heat exhaustion, heat stroke and dehydration.
During an interview on 10/17/24 at 11:06 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated that on 9/29/24 she was alerted by the housekeeping staff that Resident 1 was sitting outside by himself when the weather was hot. LVN 1 stated the certified nursing assistant (CNA) assisted Resident 1 back into the facility. LVN 1 stated Resident 1 was assessed, and he felt hot with an elevated temperature of 101 .1 degrees Fahrenheit and an elevated heart rate of 136. LVN 1 stated they immediately began cooling measures and continuous monitoring. LVN 1 stated a full head to toe skin assessment was completed, and Resident 1 had no visible injuries. LVN 1 stated she spoke with the AA and concluded Resident 1 was left outside for approximately one hour. LVN 1 stated the AA indicated she had taken Resident 1 outside; forgot he was there, and it was not in her job duties to monitor Resident 1 while he was outside. LVN 1 stated the CNA on shift and LVN 1 were not made aware that Resident 1 was taken outside. LVN 1 stated when Resident 1 was left outside there was a risk for dehydration and heat exhaustion.
During an interview on 10/17/24 at 11:32 a.m. with activities assistant (AA) 1, the AA 1 stated part of the activities for the facility was for the residents to have the option to go outside. AA 1 stated every resident should have been monitored when they were sitting outside. AA 1 stated while residents were outside in hot wheather, it was the responsibility of the AA assigned to offer cold water or popsicles to keep residents from overheating. AA 1 stated it was the responsibility of the AA on shift to monitor all residents that were in the activities room. AA 1 stated that residents could have requested to go outside but on days when the temperature was above 80 degrees Fahrenheit, they would not do an outside activity to avoid exposing the residents to the heat. AA 1 stated that when Resident 1 was left outside he could have been sun burned or possibly dehydrated.
During an interview on 10/17/24 at 11:38 a.m. with CNA 1, CNA 1 stated it was not appropriate for Resident 1 to have been left outside unmonitored. CNA 1 stated when Resident 1 was left outside there was a potential for heat exhaustion or could have caused Resident 1 to lose consciousness from dehydration.
During an interview on 10/17/24 at 12:15 p.m. with the DON, the DON stated it was the facility's expectation for all staff including the activities staff, to monitor all residents when they were outside and to not leave them unattended. The DON stated it was the responsibility of the AA to monitor Resident 1 while he was in the activities room and outside. The DON stated it was not appropriate when the CNA left Resident 1 outside and did not remain with resident to monitor. The DON stated there was a potential for heat exhaustion when Resident 1 was left outside.
During a telephone interview on 10/17/24 at 12 :24 p.m. with the administrator (ADM), the ADM stated the employee involved was properly trained on neglect and chose not to follow the training. The ADM stated it was not appropriate for the employee to have left Resident 1 outside unmonitored because he should have been monitored. The ADM stated when he spoke with the employee, she was aware Resident 1 was outside but did not monitor. The ADM stated the employee had been terminated from the facility.
During a review of the facility's Activity Assistant Job description, undated, the job description indicated, . To provide routine care and services to clients that supports the medical model of care in the Activities Department . Employees will be required to perform any other job related duties requested by their supervisor . Implements an interactive daily program, including large and small groups, special events, and community outings, provides one to one programming for clients who are unable or unwilling to participate in group programs . Meet the client's mental health and social needs, be aware of developmental tasks and physiological changes associated with the aging process, maintain/ support the client's right to maintain personal choices . Provide supervision and assistance to all residents when participating in indoor or outdoor activities .
During a review of the facility's policy and procedure (P&P) titled, Abuse Prevention Program, dated 1/2024, 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 required to treat the resident's symptoms . As part of the resident abuse prevention, the administration will, Protect our residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to maintain a comfortable environment for one of 35 residents (Resident 12) when the room temperature, measured by the California Department of Public Health (CDPH) thermometer, in Resident 12 ' s room was 84 degrees Fahrenheit.
This failure had the potential to result in dehydration (body does not have enough fluids) and heat exhaustion (body overheats and unable to cool itself) for Resident 12.
Findings:
During a concurrent observation and interview on 6/7/24 at 11:59 p.m. with the unit clerk (UC), the temperature in Resident 12 ' s room was observed. The temperature with the CDPH handheld thermometer read 84 degrees Fahrenheit. The unit clerk was observed checking the temperature of Resident 12 ' s room with the facility ' s handheld thermometer, the temperature was observed at 81 degrees Fahrenheit. The UC stated Resident 12 ' s room felt hot and hot air was being transferred into the room through the air conditioner vent. The UC stated the temperature range should have been 71-81 degrees.
During a concurrent observation and interview on 6/7/24 at 12:00 p.m. with Resident 12, Resident 12 ' s room appeared humid and hot, Resident 12 was observed lying in bed covered in a bed sheet and wearing a gown. A floor fan was observed at the corner of the room turned off. Resident 12 stated her room felt hot but did not want the floor fan turned on. Resident 12 stated she did not want an ice pack, floor fan, popsicle or to remove her bed sheet. Resident 12 stated she would have preferred for the facility to fix the AC unit rather than change her comfortability.
During a review of Resident 12's admission Record (a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated Resident 12 was admitted to the facility on [DATE] with diagnosis for chronic pain syndrome, rheumatoid arthritis (inflammation of the joints), lupus (illness that attacks the immune system), anxiety (feeling of worry, unease and nervous) and fibromyalgia (disorder that causes pain in the muscles).
During a review of Resident 12's Minimum Data Set [MDS a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment] dated 5/2/24, the MDS indicated, Resident 12's Brief Interview for Mental Status (BIMS screening tool used to assess resident cognitive level) score was 15 out of 15 (0 - 7 indicated severe cognitive impairment [memory loss, poor decision making skills] 8 12 moderate cognitive impairment, (13 -15) cognitively intact) which indicated Resident 1 was cognitively intact.
During an interview on 6/7/24 at 1:53 p.m. with the administrator (ADM), the ADM stated Resident 12 ' s room was above the temperature range at 84 degrees due to the air conditioner (AC) not circulating the air properly. The ADM stated the temperature range should have been 71-81 degrees. The ADM stated the technician was onsite to inspect the AC unit and fix the issue.
During an interview on 6/7/24 at 2:05 p.m. with CNA 1, CNA 1 stated the facility felt hot the day prior when the temperature outside was high. CNA 1 stated there were complaints from residents about the facility temperature when the temperature would rise.
During an interview on 6/7/24 at 2:31 p.m. with LVN 2, LVN 2 stated Resident 12 ' s room felt hot and humid.
During an interview on 6/7/24 at 2:43 p.m. with the director of nurses (DON), the DON stated the facility temperature felt hot the day prior due to rising temperatures outside. The DON stated there was a technician onsite to address the issue with the AC not circulating the air in Resident 12 ' s room. The DON stated the temperature in Resident 12 ' s room at 84 degrees should have been 71-81 degrees for the resident to be in a comfortable environment.
During a review of the facility ' s policy and procedure (P&P) titled, Emergency Procedure-Utility Outage, dated 1/2024, the P&P indicated, . Residents will remain safe and comfortable during a temporary loss of utility . utilize the following procedures if there is a loss of cooling functions (the facility temperature reaches 85 degrees Fahrenheit and remains so for four hours) . Monitor environmental thermometers .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to conduct and document a facility-wide assessment to determine what resources were necessary to competently care for 49 of 49 residents at the facility during day-to-day operations and emergencies.
This failure had the potential for residents not to receive the services needed to achieve and maintain the highest practicable well-being during day-to-day operations and during an emergency.
Findings:
During the entrance conference interview with the Administrator (ADM) on 1/22/24, at 9:54 a.m., the facility assessment was requested which was part of the list of documents he needed to provide in a timely manner. The Entrance Conference form indicated the ADM was to provide the facility assessment within 4 hours of entrance.
During an interview on 1/24/24 at 10:15 a.m. with the ADM, the ADM stated the skilled nursing facility (SNF) was part of the general acute care hospital (GACH) and the facility assessment was part of the campus wide assessment. The ADM would not directly answer if the SNF was assessed separately to address the individual needs of facility residents.
During an interview on 1/24/24 at 4:17 p.m. with the ADM, the ADM was unable to locate a SNF facility assessment.
During an interview on 1/25/24 at 4:18 p.m. the ADM provided a copy of the facility assessment dated [DATE] which indicated it had been reviewed on 1/31/24.
During a concurrent interview and record review on 1/26/24 at 2:00 p.m., with the ADM, the facility assessment was reviewed. The assessment indicated, . Date(s) of Assessment or Updated . January 4, 2024 . Date(s) Assessment Reviewed w/ QAA/QAPI Committee 1/31/24 . The ADM was unable to explain why the reviewed date was in the future.
During an interview on 1/26/24 at 3:58 p.m. with the ADM. The ADM stated he was unable to provide evidence of a previous facility assessment and was unsure if the facility assessment had been updated annually according to regulations. The facility was unable to provide a policy and procedure for the facility assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to promote dignity and respect for one of two sampled residents (Resident 98), when the staff failed to answer Resident 98's call light in a timely manner.
This failure resulted in Resident 98 urinating on himself and sitting in his urine for approximately 21 minutes. Resident 98 verbalized feeling felt frustrated, embarrassed, and helpless.
Findings
During a review of Resident 98's admission Record (AC), undated, the AC indicated,
Resident 98 was admitted to the facility on [DATE] for rehabilitation after closed fracture of the lower end of left femur (broken upper bone of leg), with diagnosis of respiratory failure (a serious condition which makes it difficult to breathe), muscle weakness, chronic combined systolic and dystolic heart failure (heart does not pump enough blood for body's needs), left artificial hip joint, benign prostatic hyperplasia without lower urinary tract symptoms, (enlarged prostate).
During a review of Residents 98's Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], indicated Resident 98's Brief Interview of Mental status assessment (BIMS - assessment of cognitive status for memory and judgement) scored 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, 00-07 indicates severe impairment and 99 indicates they are unable to complete the interview). The BIMS assessment indicated Resident 98's BIMS score was 15 cognitively intact.
During an observation on 1/22/24 at 10:55 a.m. in the hall outside of Resident 98's room, the call light was flashing above the door, the call light was audible, and the resident was calling out for help to urinate. There were pounding sounds coming from the room.
During an observation on 1/22/24 at 11:02 a.m. in the hall outside of Resident 98's room, the call light continued to flash and ring as it had not been answered. Certified Nursing Assistant (CNA) 2 was observed rolling a cart with snacks in and out of the rooms in the hall. CNA 2 entered Resident 98's room, turned off the call light and was heard asking the Resident 98 if he needed anything. Resident 98 stated, . it is too late now, I have already wet all over the bed and myself . I couldn't find the urinal . CNA 2 stated, .let me get your CNA to clean you up .
During a concurrent observation and interview on 1/22/24 at 11:03 a.m. with CNA 2 in the hall outside of Resident 98's room, CNA 2 stated Resident 98 was not part of her group, and she was busy handing out passing snacks to the residents. CNA 2 continued to go down the hall and passing out snacks. CNA 2 did not inform anyone that Resident 98 needed assistance.
During an interview on 1/22/24 at 11:15 a.m. with Resident 98 in his room, Resident 98 stated he pushed the call light because he could not find his urinal and he had to go to the bathroom. Resident 98 stated he was no longer able to get up without assistance. Resident 98 stated he was sitting in his own urine and felt frustrated, embarrassed, and helpless.
During an observation on 1/22/24 at 11:16 a.m. in the hall outside of Resident 98's room, CNA 2 and CNA 8 were observed going into Resident 98's room. Resident 98 was heard telling the CNAs he did not want to urinate in his bed or himself, but he could not wait any longer.
Resident 98 had been unassisted and sitting in his urine for greater than 21 minutes (from 10:55 a.m. to 11:16 a.m.).
During an interview on 1/22/24 at 2:44 p.m. with CNA 2, CNA 2 stated .call lights should be answered within 15 minutes, sooner if the resident needed to go to the bathroom . CNA 2 stated she did not answer Resident 98's call light because Resident 98 was not part of her group, and she was busy passing out snacks to the other residents. CNA 2 stated, there were three CNAs working at the time of the incident. CNA 2 stated one of the CNAs was taking her lunch break and Resident 98's CNA was busy in another room. CNA 2 stated she did go into Resident 98's room, turned off his call light and offered him a snack. CNA 2 stated Resident 98 did inform her that he had urinated on himself and on the bed. CNA 2 stated she did not assist Resident 98 because she had to continue to pass out snacks to the other residents and she did not notify anyone that Resident 98 needed help because she did not want to leave the snack cart unattended. CNA 2 stated, she should have waited until there were three CNAs available before she passed out snacks. CNA 2 stated she should have assisted Resident 98 or sent someone in to help him.
During an interview on 1/25/24 at 10:45 a.m. with the Director of Staff Development (DSD), the DSD stated CNA 2 did not follow call light policy and did not meet the expectations of her position. DSD stated it was the expectation of the facility that call lights were answered within fifteen minutes regardless of whose group the Resident was in. DSD stated CNA 2 should not have been passing out snacks while there were only two CNA on the floor. CNA 2 left only one CNA to assist residents which resulted in Resident 98 urinating on himself and having to sit in soiled clothes. DSD stated leaving residents in soiled wet clothes puts them at risk for embarrassment and skin breakdown.
During an interview on 1/25/24 at 10:45 a.m. with Director of Nursing (DON), the DON stated the CNA 2 did not follow call light policy resulting in Resident 98 feeling embarrassed and frustrated. DON stated, CNA 2 put other residents in danger when she decided to pass out snacks leaving only one CNA to care for the residents alone. DON stated CNA 2 did not work per expectations of the facility.
During review of the facility's policy and procedure (P&P) Quality of Life - Dignity dated 8/2009, indicated .11. Demeaning practices and standards of care that compromise dignity are prohibited. Staff shall promote dignity and assist residents as needed by: .b. Promptly responding to the resident's request for toileting assistance .
During a review of the facility's policy Answering the Call Light dated 10/2010, indicated .General Guidelines .8. Answer the resident's call as soon as possible .6. If assistance is needed when you enter the room, summon help by using the call signal .
During a review of the facility's job description for Certified Nurses [undated] indicated, . Performs Patient Care Activities Appropriately .B. Answers patient lights and performs services in a timely manner that adds to the physical well-being of the patient .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to maintain a clean and homelike environment for three of three sampled residents (Residents 6, 147 and 19), when:
1. The door frame of Resident 6's Room had missing and chipped paint.
2. Ceiling tiles were peeling, paint missing from Resident 147's room.
3. Resident 19's wall had a TV bracket in place without a television (TV) for over one month, which Resident 19 complained to staff about not having a TV in her room.
These failures had the potential to violate the residents' rights to have a clean, sanitary, and comfortable homelike environment.
Findings:
1. During a review of Resident 6's admission Record (AR), dated 1/25/24, the AR indicated Resident 6 was admitted on [DATE] with diagnoses which included quadriplegia (a form of paralysis [the loss of the ability to move and sometimes to feel anything] that affects all of a person's limbs and body from the neck down), chronic pulmonary embolism (blockage of the pulmonary [lung] arteries that occurs when prior clots in these vessels don't dissolve over time despite treatment), and presence of cardiac pacemaker (a small, battery-powered device that prevents the heart from beating too slowly).
During a review of Resident 6's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 12/18/23, the MDS Section C indicated Resident 6 had a BIMS (Brief Interview for Mental Status - a test given by medical professionals to determine cognitive understanding on a scale of 1-15 ) of 15 out of 15 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact) which suggested Resident 6 was cognitively intact.
During an observation on 1/24/24 at 9:22 a.m. outside of Resident 6's room, the door frame entering the room had missing and chipped paint.
During a concurrent observation and interview on 1/25/24 at 1:32 p.m., with Resident 6, inside of Resident 6's room, Resident 6 stated the missing paint on the door frame bothered him, this was his home, and the facility had not painted the door frame for months. Resident 6 stated, if he was able, he would have painted the door frame immediately after the paint had peeled off. Resident 6 stated, the ceiling tiles and paint missing from the ceiling area above Resident 147's room had been peeling since the COVID (Infectious disease caused by a virus) divider was removed. Resident 6 stated, It is an eye soar, it feels as if the facility does not care about providing a home like environment.
During a concurrent interview and record review on 01/26/24 at 11:42 a.m., with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Quality of Life - Homelike Environment, dated May 2017, was reviewed. The P&P indicated, .Residents are provided with a safe, clean comfortable environment . DON stated the missing paint on the door frames, wall, and ceiling tiles, should have been repaired quickly. The DON stated the facility did not follow the policy for providing a home like environment. DON stated this could cause the residents to feel they were not cared for.
2. During a review of Resident 147's AR, dated 1/24/24, the AR indicated Resident 147 was admitted on [DATE] with diagnoses which included major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities), and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities).
During a review of Resident 147's (MDS), dated 1/16/24, the MDS Section C indicated Resident 147 had a BIMS of 9 which suggested Resident 147 was moderately impaired.
During an observation on 1/24/24 at 9:24 a.m. the ceiling area above Resident 147's room, the ceiling tiles were peeling and missing paint from the wall near the ceiling.
During a concurrent observation and interview on 1/25/24 at 2:20 p.m., with Resident 147, in Resident 147's room. Resident 147 stated she had to look at the damaged wall and ceiling every time she left her room. Resident 147 stated she felt as if the facility did not care about fixing the building for the residents. Resident 147 stated she was frustrated by the damaged wall and ceiling.
During a concurrent interview and record review on 01/26/24 at 11:42 a.m., with the DON, the facility's policy and procedure (P&P) titled, Quality of Life - Homelike Environment, dated May 2017, was reviewed. The P&P indicated, .Residents are provided with a safe, clean comfortable environment . DON stated the missing paint on the door frames, wall, and ceiling tiles, should have been repaired quickly. The DON stated the facility did not follow the policy for providing a home like environment. DON stated this could cause the residents to feel they were not cared for.
3. During a review of Resident 19's AR, dated 1/25/24, the AR indicated Resident 19 was admitted on [DATE] with diagnoses which included major depressive disorder, anxiety disorder, and osteomyelitis, (an inflammation or swelling of bone tissue that is usually the result of an infection).
During a review of Resident 19's MDS, dated 1/25/23, the MDS section C indicated Resident 19 had a BIMS of 15, which suggested Resident 19 was cognitively intact.
During a concurrent observation and interview on 1/22/24 at 11:12 a.m. with Resident 19, in Resident 19's room, Resident 19's wall was observed to have a TV bracket, with no TV. Resident 19 stated the TV had been missing for one month. Resident 19 stated her TV broke and it was reported. Resident 19 stated she was still waiting for a TV. Resident 19 stated she was straining her neck trying to watch TV on her roommate's TV.
During an interview on 1/24/24 at 11:02 a.m. with the Social Services Director (SSD), the SSD stated she was aware of Resident 19's room missing a TV. The SSD stated Resident 19's TV quit working and they had ordered a new TV, but it did not fit on the old wall mount. The SSD stated new brackets were ordered, but they had not received the brackets. The SSD stated the Assistant Administrator ordered the TV and brackets but had been out on leave.
During a review of the Work Order Request Form Maintenance Department (Work Order), dated 12/6/23, the Work Order indicated, .Please install new TV in Resident [19]'s room. TV is in the front office, same TV's, bracket should work . Please order new compatible wall mount .
During a concurrent interview and record review on 01/26/24 at 11:42 a.m., with the DON, the facility's policy and procedure (P&P) titled, Quality of Life - Homelike Environment, dated May 2017, was reviewed. The P&P indicated, .Residents are provided with a safe, clean comfortable environment . The DON stated the facility did not follow the policy for providing a home like environment. This could cause the residents to feel they were not cared for.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure staff followed professional standards of practice when:
1. Facility staff did not obtained consent for psychoactive medication (medication that changes brain function and results in alterations in perception, mood, consciousness, cognition, or behaviors), vaccinations (preparation to stimulate the body's immune response against disease), side rails and his Physician Orders for Life-Sustaining Treatment (POLST-a legal document that specifies the type of care a resident's treatment and services would like in an emergency life threatening medical situation) while lacking decision-making capacity for informed consent (healthcare provider educates a patient about risks, benefits and alternatives of an intervention and the patient must be competent to make voluntary decisions) for one of three sampled residents (Resident 13) .
These failures placed Resident 13 at risk for harm from giving consent without full understanding of the risks versus benefits for the psychoactive medication, vaccinations, side rails and his POLST.
2. One of six sampled Residents (Resident 18) refused medications on multiple occasions and the licensed nurses failed to notify the resident's physician.
This failure placed Resident 18's health at risk for not receiving the medication's therapeutic benefits.
3. One of three sampled residents (Resident 14) was given pain medication outside of the physician ordered parameters for administration.
This failure placed Resident 14 at risk for his pain being treated inappropriately causing adverse side effects.
4. Licensed nurses administered medication to three of six sampled residents (Residents 18, 26 and 147) without providing privacy.
This failure placed Resident 18, 26 and 147's dignity and privacy at risk for being violated.
5. Licensed Vocational Nurse (LVN) 2 left insulin (a medication which controls the amount sugar in the blood) unattended on Resident 18's bedside table.
This failure placed Resident 18's health and safety at risk when the medication was left accessible and had the potential for ingestion and contamination of the bottle.
6. LVN 1 left Resident 32's liquid medication unattended at bedside.
This failure left Resident 32 at risk for not receiving the therapeutic benefits of the medication.
Findings:
1. During an observation on 01/22/24 at 10:27 a.m. in Resident's room, Resident 13 was lying in bed with his eyes closed. Resident 13 did not respond when spoken to.
During a review of Resident 13's admission Record [AR], undated, the AR indicated, Resident 13 was admitted to the facility on [DATE] with diagnoses included sequelae of cerebral infarction (neurological deficits remaining after a cerebral vascular accident [stroke-blockage in a blood vessel in the brain]), dementia (loss of cognitive functioning (thinking, remembering and reasoning), psychoactive substance abuse (drug dependence affecting a person's brain and behavior) and anxiety disorder (persistent and excessive worry). The AR indicated Resident 13 was his own responsible party. The AR also had contact information for two family members.
During a review of Residents 13's Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], indicated Resident 13's Brief Interview of Mental status assessment (BIMS - assessment of cognitive status for memory and judgement) scored 99 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, 00-07 indicates severe impairment and 99 indicates they are unable to complete the interview). The BIMS assessment indicated Resident 13 was unable to participate in the assessment.
During a review of Resident 13's psychiatrist's progress note dated 12/11/2023, the note indicated, . h/o [history of] Dementia and stroke . He is a poor historian . He is alert and oriented X[times]1 and has periods of confusion . Assessments . Neurocognitive disorder [decreased mental function and loss of ability to do daily tasks] .
During a concurrent interview and record review on 1/26/24 at 8:39 a.m. with Licensed Vocational Nurse 1 (LVN) 1, Resident 13's electronic medical record (EMR) was reviewed. LVN 1 stated Resident 13 was forgetful with confusion and only capable of answering simple questions. LVN 1 reviewed Resident 13's Side Rails Informed Consent and Release, and stated Resident 13 signed the consent on 10/31/22 which she had witnessed. LVN 1 stated she was not sure if Resident 13 understood what he had consented to or the risks versus benefits of the side rails. LVN 1 stated she did not think it was appropriate for him to give consent. The informed consents for sertraline (psychoactive medication used to treat depression and other mental illnesses), influenza (highly contagious respiratory infection) and respiratory syncytial virus (RSV-respiratory virus causing infection of the lungs and respiratory tract) vaccinations were reviewed, LVN 1 stated Resident 13 had signed the informed consents, but she did not think Resident 13 could fully understand the risks versus benefits of the medication and vaccinations. Resident 13's POLST was reviewed, Resident 13 signed the POLST on 7/26/23. LVN 1 stated the POLST was a life sustaining decision and Resident 13 should not have signed the POLST himself because she did not think he could fully comprehend it. LVN 1 stated Resident 13's family or the Interdisciplinary Team (IDT-a group of health professionals working together to help a resident make decisions and meet goals) should him to make the decision. LVN 1 stated, I do not think he can make his own decisions. He should not be his own RP [responsible party]. LVN 1 stated if a resident was incapable to be their own RP the facility would reach out to the next of kin, and if next of kin was unable to, the IDT would assist. During a review of Resident 13's care plan for impaired cognitive function, the care plan indicated, . [Resident 13] has impaired cognitive function or impaired thought processes r/t [related to] Dementia . oriented to name only, follows simple direction . able to make simple decisions . such as what clothes to wear . Interventions . Ask yes/no questions in order to determine [Resident 13's] needs . cue, reorient and supervise as needed . Present just one thought, idea, question or command at a time . LVN 1 stated Resident 13 needed time to process his thoughts and could answer one question at a time.
During a concurrent interview and record review on 1/26/24 at 9:04 a.m. with the Social Services Director (SSD) Resident 13's sertraline informed consent was reviewed. The SSD stated Resident 13 was difficult to understand when speaking. The SSD stated a Resident would need to be alert and oriented to give consent for psychiatric medication. The SSD stated Resident 13 did not fully understand all risks possible from the medication. The SSD reviewed Resident 13's psychiatrists progress note dated 12/11/23 and stated the note indicated Resident 13 was alert times one which meant only to himself. The SSD stated she had never called Resident 13's family because she never had the need to. The SSD stated Resident 13's family should have been contacted regarding the informed consent.
During a concurrent interview and record review on 1/26/24 at 9:18 a.m. with the Minimum Data Set Coordinator (MDSC), Resident 13's diagnosis and BIMS were reviewed. The MDSC stated Resident 13 had a diagnosis of dementia and BIMS of 99 which indicated he was unable to participate in the cognitive assessment. The MDSC stated, It is not appropriate for him [Resident 13] to be his own RP. Resident 13's informed consents for RSV and Flu vaccinations, side rails, sertraline and the POLST were reviewed. The MDSC stated Resident 13 would need to understand what he was consenting to, including the potential risks versus benefits for them to be valid.
During an interview on 1/26/24 at 11:07 a.m. with the Director of Nursing (DON), the DON stated informed consents were acquired for admission, treatment, psychotropic medication, side rails and restraints. The DON reviewed Resident 13's EMR and stated Resident 13 had a diagnosis of dementia. The DON stated Resident 13 was not capable of giving informed consent on his own. Resident 13's POLST was reviewed, and the DON stated he had signed his POLST himself, but it not valid because of his limited decision making capacity. The DON reviewed the informed consents for side rails, sertraline, flu and RSV vaccines. The DON stated she did not consider those consents valid and would contact the family. The DON stated if a resident was not able to make decisions or give consent the family should be contacted next. The DON stated the next step would be for the IDT to meet and discuss the risks versus benefits and what was in the resident's best interest. The DON stated the facility had not had an IDT meeting to determine if it was appropriate for Resident 13 to be his own RP. The facility's policy and procedure (P&P) titled, Informed Consent, dated 3/2019, was reviewed with the DON. The P&P indicated, . Informed consent is a process of providing information, ensuring shared understanding and making decisions in the context of the Resident's needs . If is important that information is provided in a language and manner that the Resident understands . This requires an assessment of learning and communication barriers . The DON stated the P&P was not followed.
During a phone interview on 1/26/24 at 11:37 a.m. with the Family Member (FM) 1, FM 1 stated Resident 13 was not capable of making decisions for himself without assistance.
During a review of a professional reference found at https://polst.org/wp-content/uploads/2018/03/2018.03.01-Surrogate-Definition-and-Role-in-Advance-Care-Planning.pdf titled Advance Care Planning: Surrogates, dated 3/1/2018, the reference indicated, . Because the POLST form orders direct a patient's medical treatments, the patient must have sufficient decision-making capacity to give consent, meaning that the patient has the mental capacity to understand his or her condition, the benefits and burdens of the proposed course of treatment .
During a review of the facility's admission agreement titled, California Standard admission Agreement for skilled Nursing Facilities and Intermediate Care Facilities, dated 5/2011, the admission agreement indicated on page 10-11, . Representative of patient; devolution of rights . Any rights under this chapter of a patient judicially determined to be incompetent or who is found by his physician to be medically incapable of understanding such information, or who exhibits a communication barrier, shall devolve to such patient's guardian, conservator, next of kin, sponsoring agency .
During a review of a professional reference found at
https://www.aafp.org/pubs/afp/issues/2018/0701/p40.html#:~:text=Capacity%20is%20the%20basis%20of,they%20can%20communicate%20their%20wishes titled, Evaluating Medical Decision-Making Capacity in Practice, dated 2018, the article indicated, .Medical decision-making capacity is the ability of a patient to understand the benefits and risks of, and the alternatives to, a proposed treatment . Capacity is the basis of informed consent. Patients have medical decision-making capacity if they can demonstrate understanding of the situation, appreciation of the consequences of their decision, and reasoning in their thought process, and if they can communicate their wishes .
2. During a review of Resident 18's admission Record [AR], undated, the AR indicated, Resident 18 was admitted to the facility on [DATE] with diagnoses which included hemiplegia (paralysis of one side of the body) and hemiparesis (one sided muscle weakness) following cerebral infarction (stroke-blockage in a blood vessel in the brain), Type 2 Diabetes Mellitus (disease in which blood glucose [sugar] is too high) and aphasia (disorder which affects ability to communicate).
During a review of Residents 18's MDS assessment dated [DATE], indicated Resident 18's BIMS scored 99 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, 00-07 indicates severe impairment and 99 indicates they are unable to complete the interview). The BIMS assessment indicated Resident 18 was unable to participate in the assessment.
During a concurrent observation and interview on 1/24/24 at 11:01 a.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 tested Resident 18's fingerstick blood sugar. LVN 2 stated Resident 18's blood sugar would require insulin 3 units according to the physician's order. Resident 18 had refused the insulin (a medication which controls the amount sugar in the blood) injection.
During a concurrent interview and record review on 1/25/24 at 9:10 a.m. with LVN 2, Resident 18's Medication Administration Record (MAR) dated 1/2024, was reviewed. LVN 2 stated when a resident refused medication, a code 2 was entered on the MAR and a progress note was written. LVN 2 stated when a resident refused medication for multiple days the physician would be notified. LVN 2 stated when a resident refused insulin it could cause adverse effects such as going into a coma (deep state of unconsciousness) from high blood sugar. LVN 2 reviewed Resident 18's MAR and stated he refused his insulin on 1/24/24 at 11:00 a.m. which was indicated on the MAR with a 2. LVN 2 reviewed Resident 18's progress notes and was unable to locate a progress note which indicated he had refused his insulin. LVN 2 stated she should have documented the refusal. LVN 2 stated Resident 18 frequently refused his medications. LVN 2 stated the physician should have been notified, but she had not notified him.
During a concurrent interview and record review on 1/25/24 at 10:18 a.m. with the Director of Nursing (DON), Resident 18's MAR and progress notes were reviewed. The DON stated Resident 18 refused medications on multiple days in January. The MAR dated 1/2024 indicated Resident 18 refused medications with a code 2 as follows:
1/5/24, 1/7/24, 1/18/24- Atorvastatin (for hyperlipidemia-high concentration of fats in the blood), Clopidogrel Bisulfate (for cerebral infarction), Sennosides-Docusate Sodium (for constipation), Xalatan ophthalmic solution (to treat glaucoma [increased pressure in the eye causing loss of sight])
1/8/24-Allopurinol (for gout [arthritis causing severe pain]), Amlodipine (for hypertension [high blood pressure]), Ascorbic Acid (vitamin C), aspirin, Atenolol (for hypertension), Fish oil (a dietary supplement), Vitamin D3 1/10/24, 1/22/24-Atorvastatin Calcium, Clopidogrel bisulfate (cerebral infarction), Sennosides-Docusate Sodium (constipation)
The DON stated her expectations when a resident refused medication was for the nurse to offer it three times, explain the risks versus benefits to the resident and if the resident continues to refuse, notify the physician. The DON stated Resident 18's physician should have been notified since he had multiple medication refusals. The DON stated when Resident 18 refused his insulin on 1/24/24, the nurse should have offered it again and followed up by rechecking the residents blood sugar. The DON stated she was unable to locate a progress note to indicate the nurse had rechecked the blood sugar or notify the physician.
During a review of the facility's policy and procedure (P&P) titled, Refusal of Treatment, dated May 2013, the P&P indicated, . Our facility shall honor a resident's request not to receive medical treatment as prescribed by his or her physician . Should the resident refuse to accept treatment, detailed information relating to the refusal must be entered into the resident's medical record . The Attending Physician must be notified of refusal of treatment, in a time frame determined by the resident's condition and potential serious consequences of the refusal .
3. During a review of Resident 14's admission Record [AR], undated, the AR indicated, Resident 14 was admitted to the facility on [DATE] with diagnoses which included acute subdural hemorrhage (bleeding between the brain and skull), rhabdomyolysis (serious medical condition cause by muscle injury), hemiplegia (paralysis of one side of the body) and hemiparesis (one sided muscle weakness) following cerebral infarction (stroke-blockage in a blood vessel in the brain) and aphasia (disorder which affects ability to communicate).
During a review of Residents 14's MDS assessment dated [DATE], indicated Resident 14's BIMS scored 11 out of 15. The BIMS assessment indicated Resident 14 had a moderate cognitive impairment.
During an interview on 1/22/24 at 10:24 a.m. with Resident 14, Resident 14 indicated by writing he had shoulder pain, was on pain medication and wanted the medication increased.
During a concurrent observation and interview on 1/24/24 at 2:47 p.m. with Resident 14, Resident 14 reported his pain was 10/10 to his left shoulder. Resident 14 was not groaning, grimacing or guarding the shoulder.
During an interview on 1/25/24 at 11:07 a.m. with Certified Nursing Assistant (CNA) 6, CNA 6 stated Resident 14 rarely complained of pain during care.
During a concurrent interview and record review on 1/26/24 at 8:31 a.m. with Licensed Vocational Nurse (LVN) 1, Resident 14's Order Summary Report, dated 1/25/24, was reviewed. The orders indicated, . Hydrocodone-Acetaminophen Oral Tablet 5-325 MG Give 1 tablet by mouth every 12 hours as needed for severe pain (7-10/10 [pain scale used to measure pain 0-3/10 mild pain, 4-6/10 moderate pain, 7-10/10 severe pain]) related to RHABDOMYOLYSIS . Resident 14's Medication Administration Record [MAR], dated 1/2024 was reviewed. LVN 1 stated the MAR indicated Resident 14 was given hydrocodone-acetaminophen 5-325 mg as follows:
1/11/24 pain level 5/10
1/12/24 pain level 0/10
1/22/24 pain level 6/10
1/23/24 pain level 0/10
LVN 1 stated Resident 14's pain was less than 7/10 and he should not have received hydrocodone-acetaminophen according to the physician's order. LVN 1 stated the physician's order was not followed.
During a concurrent interview and record review on 1/26/24 at 11:23 a.m. with the Director of Nursing (DON), Resident 14's MAR and physician order for hydrocodone-acetaminophen were reviewed. The DON stated the nurses administered the medication when the pain was lower than 7/10 and did not follow the physician's order. The DON stated her expectation was for the nurses to follow the physician's order.
During a review of the facility's policy and procedure (P&P) titled, Administering Medications, dated 12/2012, the P&P indicated, . Medications shall be administered in a safe and timely manner and as prescribed . Medications must be administered in accordance with the orders .
4. During an observation on 1/24/24 at 7:29 a.m. with Licensed Vocational Nurse (LVN) 3, LVN 3 administered medication to Resident 147 with the privacy curtain and door open.
During an observation on 1/24/24 at 7:44 a.m. with LVN 3, LVN 3 administered Resident 26's medication while privacy curtain was not closed and her roommate was in the next bed.
During an interview on 1/24/24 at 7:54 a.m. with LVN 3, LVN 3 stated she should have closed Residents 147 and 26's privacy curtains. LVN 3 stated the residents were in the room together and did not have privacy while taking their medications. LVN 3 stated she had forgotten to close the curtains.
During a concurrent observation and interview on 1/24/24 at 11:01 a.m. with LVN 2, LVN 2 walked into Resident 18's room and checked the residents blood sugar while the curtain and door were left open. LVN 2 stated she should have closed the curtain to give the resident privacy during the procedure.
During an interview on 1/25/24 at 10:18 a.m. with the Director of Nursing (DON), the DON stated her expectations for medication pass was for the nurses to provide the residents' privacy. The DON stated the curtains should be closed to respect the residents' dignity.
During a review of the facility's document titled, Licensed Practical/Vocational Nurse (LVN) Job Description, the job description indicated, . Using independent and interdependent judgment, the Licensed Vocational/Practical Nurse (LVN/LPN) maintains the delivery of quality care . Protect the privacy of patients .
During a review of the facility's policy and procedure (P&P) titled, Quality of Life-Dignity, dated 8/2009, the P&P indicated, . Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality . Staff shall promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures .
5. During a review of Resident 18's admission Record [AR], undated, the AR indicated, Resident 18 was admitted to the facility on [DATE] with diagnoses which included hemiplegia (paralysis of one side of the body) and hemiparesis (one sided muscle weakness) following cerebral infarction (stroke-blockage in a blood vessel in the brain), Type 2 Diabetes Mellitus (disease in which blood glucose [sugar] is too high) and aphasia (disorder which affects ability to communicate).
During a review of Residents 18's MDS assessment dated [DATE], indicated Resident 18's BIMS scored 99 The BIMS assessment indicated Resident 18 was unable to participate in the assessment.
During a concurrent observation and interview on 1/24/24 at 11:01 a.m., with LVN 2, in Resident 18's doorway. LVN 2 gathered supplies to test Resident 18's blood sugar and placed the supplies with his insulin bottle into a plastic cup. LVN 2 took the cup into Resident 18's room and placed it on the bedside table. LVN 2 tested Resident 18's blood sugar, left the bottle of insulin on his bedside table and exited the room. Resident 18's insulin was left unattended and accessible. LVN 2 stated, The insulin was left in the room. I should not have left it there. LVN 2 stated Resident 18 had access to the insulin and could have contaminated it.
During an interview on 1/25/24 at 10:18 a.m. with the Director of Nursing (DON), the DON stated medication should never be left at a resident's bedside because it was a safety issue. The DON stated her expectation was for the nurses to keep medication in their possession or in line of site.
During a review of the facility's policy and procedure (P&P) titled Administering Medications, dated 12/2012, the P&P indicated, . Medications shall be administered in a safe and timely manner, and as prescribed . During administration of medications, the medication cart will be kept closed and locked when out of sight of the medication nurse . No medications are kept on top of the cart . cart must be clearly visible to the personnel administering medications . must be inaccessible to residents or others passing by .
6. During a concurrent observation and interview on 1/22/24 at 9:45 a.m. in Resident 32's room, a plastic cup with a slightly translucent liquid and spoon was sitting on the bedside table. Resident 32 stated the cup had his medication to help him 'go' and rubbed his stomach. Resident 32 stated the nurse poured a powder into the water, mixed it and left it at bedside.
During a review of Resident 32's admission Record [AR], undated, the AR indicated, Resident 32 was admitted to the facility on [DATE] with diagnoses which included chronic respiratory failure (condition in which your blood does not have enough oxygen) and chronic obstructive pulmonary disease (COPD- group of diseases that block airflow and make it difficult to breathe).
During a review of Residents 32's MDS assessment dated [DATE], indicated Resident 32's BIMS. The BIMS assessment indicated Resident 32 had a moderate cognitive impairment.
During a concurrent observation and interview on 1/22/24 at 10:16 a.m. with Licensed Vocational Nurse (LVN) 1 at Resident 32's bedside, the plastic cup with the translucent liquid was observed. LVN 1 stated she had given Resident 32's [brand name for polyethylene glycol- a laxative for constipation] this morning and left it at bedside. LVN 1 stated the polyethylene glycol was a medication and should not have been left at bedside. LVN 1 stated she should have watched Resident 32 take the medication to verify he did. LVN 1 stated another resident could have access to the medication when left at bedside. LVN 1 stated if someone took the medication and it was not prescribed to them, they could have abdominal pain and diarrhea.
During an interview on 1/25/24 at 10:18 a.m. with the Director of Nursing (DON), the DON stated medication should never be left at a resident's bedside. The DON stated her expectation was for the nurses stay with the residents and make sure the medication was taken. The DON stated it was a safety issue to leave the medication at bedside.
During a review of a facility document titled, Back to the Basics Medication Administration and Storage, dated 2017, the document indicated, . oral medications . Residents should be observed swallowing all medication .

Based on observation, interview, and record review, the facility failed to ensure medications were labeled in accordance with professional standards for 24 of 31 residents when medication blister packs (a type of packing used for resident medication) had orange and green stickers placed over the expiration dates.
These failures placed residents at risk for being administered expired medications which may have no longer had the same efficacy and/or side effects.
Findings:
During a concurrent observation and interview on 1/24/24 at 10:12 a.m., with Infection Preventionist (IP - professional who make sure healthcare workers and residents are doing all the things they should to prevent infections) at medication cart 1, 24 of 31 residents' medication blister packs were observed with no visible expiration date. The expiration date was covered with orange and green stickers indicating am (morning) and pm (afternoon) shifts. IP stated he could not find an expiration date on medication blister packs. IP stated not being able to see expiration date put the residents at risk to receive expired medications.
During a concurrent observation and interview on 1/24/24 at 10:15 a.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated she was unable to find the expiration date on 24 resident medication blister packs. LVN 2 stated the stickers were placed over the expiration dates. LVN 2 stated she placed the stickers on the blister packs and that was her practice. LVN 2 validated she had been administering these medications to residents. LVN 2 stated she was not following the facility's policy for medication administration because she could not check the expiration date prior to administering medication to residents. LVN 2 stated if the residents received expired medications, the resident could have potential side effects or ineffective treatment due to medication no longer having desired efficacy.
During a concurrent interview and record review on 1/25/24 at 10:58 a.m. with Director of Nursing (DON), the facility's policy, and procedure (P&P) titled, Administering Mediations dated 12/2012 was reviewed. The P&P indicated, .9. The expiration/beyond use date on the medication label must be checked prior to administering DON stated stickers should not be placed over the expiration date. The DON stated the nurse would not be able to verify if the medication had expired. The DON stated the nurse could give residents expired medications that may have lost its efficacy.
During a review of the Federal Drug Administration (FDA)'s article titled Pharmaceutical-quality-resources/expiration Dates dated 10/2022, the Pharmaceutical-quality-resources/expiration Dates indicated . Drug expiration dates reflect the time period during which the product is known to remain stable, which means it retains its strength, quality, and purity .

Based on observations, interviews, and record review, the facility failed to ensure kitchen staff had the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, in accordance with professional standards for food service safety when one of two sampled kitchen staff (Cook 2) were not able to verbalize the appropriate method of the food cool down process.
This failure had the potential to result in the growth of spore-forming bacteria (highly resistant, dormant [no metabolic activity] structures formed in response to adverse [unfavorable] environmental conditions) or toxin-forming bacteria (organisms which are capable of producing toxins [substances that are poisonous to humans]) on improperly cooled food, resulting in bacterial food born illness (illness caused by ingestion of contaminated food or beverages) for 49 out of 49 residents who consumed food from the kitchen.
Findings:
During a concurrent observation and interview on 1/23/24 at 9:05 a.m. with [NAME] (CK) 2 in the kitchen, CK 2 was asked about the cool down process for hot foods. CK 2 stated, The cool down process of hot foods was to note the temperature of the food immediately from taking it out of the oven and two hours later check the temperature and after four hours check the temperature again. CK 2 was not able to state the safe temperature reading at the first two hours.
During a concurrent interview and record review on 1/23/24 at 9:12 a.m. with the Certified Dietary Manager (CDM), the [Facility] Cool Down Log, dated 1/10/24 was reviewed. The [Facility] Cool Down Log indicated, .Bread pudding temperature at 11:00 a.m. was listed at 189 degrees F. [Fahrenheit], at 1:00 p.m. the temperature reading was at 169 degrees F., at 5:00 p.m. the temperature reading was at 40 degrees F . The CDM stated the bread pudding cool down process was not correctly followed. The CDM stated the cooling temperature should have started at 140 degrees F.
During a concurrent interview and record review on 1/24/24 at 1:25 p.m. with the CDM, the facility's policy and procedure (P&P) titled, Cooling and Reheating of Potentially Hazardous or Time/Temperature Control for Safety Food, dated 2023, indicated, . When cooked PHF [ Potentially Hazardous Food] or TCS [Time/Temperature Control for Safety] food will not be served right away it must be cooled as quickly as possible . Cool cooked food from 140 degrees Fahrenheit [F] to 70 degrees F within two hours. Then cool from 70 degrees F to 41 degrees F or less in an additional four hours for a total cooling time of six hours . The CDM stated his expectation was that staff was aware of procedures and followed guidelines. The CDM stated his expectation was that, we served tasty, healthy, and palatable food.
During a review of In-service Program Sign-in Sheet, Cooling and Reheating of Hazardous Foods dated 4/25/23, the In-service Program Sign-in Sheet, Cooling and Reheating of Hazardous Foods did not show if the CK 2 had attended the in-service.
During a review of professional reference titled, FDA Food Code 2022, section 3-501.14 Cooling, dated 2022, indicated, .Safe cooling requires removing heat from food quickly enough to prevent microbial growth. Excessive time for cooling of time/temperature control for safety foods has been consistently identified as one of the leading contributing factors to foodborne illness. During slow cooling, time/temperature control for safety foods are subject to the growth of a variety of pathogenic microorganisms. A longer time near ideal bacterial incubation temperatures, 21oC [degrees Celsius] - 52oC (70oF [degrees Fahrenheit] - 125oF), is to be avoided. If the food is not cooled in accordance with this Code requirement, pathogens may grow to sufficient numbers to cause foodborne illness. The Food Code provision for cooling provides for cooling from 135ºF to 41°F or 45°F in 6 hours, with cooling from 135ºF to 70°F in 2 hours . The initial 2-hour cool is a critical element of this cooling process . if cooling from 135ºF to 41°F or 45°F is achieved in 6 hours, but the initial cooling to 70ºF took 3 hours, the food safety hazards may not be adequately controlled
During a review of professional reference titled, FDA Food Code 2022, section 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding, dated 2022, indicated, .Bacterial growth and/or toxin production can occur if time/temperature control for safety food remains in the temperature [Danger Zone] of 5oC to 57oC (41oF to 135oF) too long .

Based on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety when:
1. There was one unwrapped frozen food item on the floor, under the food rack in the walk-in freezer.
This failure had the potential for pathogenic microorganism (an organism that is so small that it cannot be seen by the naked eye and is capable of causing disease) growth that could inadvertently (accidentally) be transferred to food and could also provide an environment for attraction of insects and rodents.
2. Residents' meal trays were reheated by staff, who were not trained on the proper method to safely reheat food for residents whose meal trays were held to be consumed at a later time.
This failure had the potential for growth of pathogenic bacteria and cause food born illness (illness caused by ingestion of contaminated food or beverages) to residents who consumed the improperly reheated food and placed residents at risk for cross-contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect).
Findings:
1. During a concurrent observation and interview on 1/22/24 at 9:36 a.m. with the Certified Dietary Manager (CDM) in the walk-in freezer, a frozen item was observed under the food storage rack. The CDM stated it looked like an unwrapped hamburger patty. The CDM stated there should be no food under the storage rack. The CDM stated the area should be clean.
During an interview on 1/23/24 at 11:12 a.m. with the CDM, the CDM stated his expectation was that the kitchen area was clean, and that staff was aware of cleaning in the kitchen.
During a review of [facility] Daily Cleaning Schedule (Cleaning Schedule), dated week of 1/22 - 1/28/2024, the Cleaning Schedule did not show staff initials for sweeping the freezer floor on 1/22 for the p.m. (afternoon) shift, and on 1/23 for the a.m. (morning) shift.
During a review of the facility's policy and procedure titled, Sanitation Section 8 dated 2023, indicated, . The FNS (Food and Nutrition Services) Director will write the cleaning schedule in which he designates by job title and/or employee who is to do the cleaning task . the kitchen staff is responsible for all the cleaning .
During a review of professional reference titled, FDA Food Code 2022, section 4-602.13 Nonfood-Contact Surfaces, dated 2022, indicated, .Non FOOD-CONTACT SURFACES of EQUIPMENT shall be cleaned at a frequency necessary to preclude accumulation of soil residues .The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests .
2. During a concurrent observation and interview on 1/23/24 at 9:36 a.m. with the CDM in the staff lounge, the resident nourishment refrigerator was observed with a resident meal tray inside the refrigerator. The CDM stated the meal tray was being held for a resident who left the facility for dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) treatment. The CDM stated they would hold the meal tray for the residents in the resident nourishment refrigerator and staff would reheat the meal tray when the residents returned from their appointments.
During an interview on 1/23/24 at 10:36 a.m. with Resident 40, Resident 40 stated staff would warm her food if it was cold.
During an interview on 1/25/24 at 9:32 a.m. with Licensed Vocational Nurse (LVN) 3, LVN 3 stated staff would hold resident's meal tray if the resident was sleeping or if the resident was not there to eat the meal. LVN 3 stated, We would store the resident's meal tray in the resident nourishment refrigerator. LVN 3 stated the Certified Nursing Assistant (CNA) would warm up the resident's meal tray when the resident came back. LVN 3 stated there was no training for reheating resident's meal trays.
During an interview on 1/25/24 at 10:38 a.m. with the Director of Staff Development (DSD), the DSD stated staff would hold a resident's meal tray if the resident was not there to eat their food. The DSD stated the CNAs would reheat the resident's meal tray when they returned from their appointments . The DSD stated the CNAs did not have a thermometer to check the food temperature. The DSD stated the CNAs would need to touch the resident's food to be sure it was warm. The DSD stated they had not done an in-service on reheating food.
During an interview on 1/25/24 at 10:57 a.m. with the CDM, the CDM stated CNAs would need to reheat food to 165 degrees Fahrenheit (F). The CDM stated residents could get a food born illnesses if the food was undercooked or over-cooked. The CDM stated the resident's mouth could get burned if the reheated food was too hot. The CDM stated he did not feel it was appropriate for CNAs to reheat food.
During an interview on 1/25/24 at 11:00 a.m. with the Registered Dietician (RD), the RD stated it was not appropriate for CNAs to reheat residents' meal trays. The RD stated the food could be outside of appropriate temperatures. The RD stated there should be better communication with the kitchen about holding residents' meal trays. The RD stated it was not appropriate for staff to touch the resident's food to see if it was warm. The RD stated staff touching the resident's food with their hands could cause cross-contamination.
During an interview on 1/25/24 at 11:33 a.m. with CNA 3, CNA 3 stated she had put residents' food in the resident nourishment refrigerator if the residents were not at the facility during meal service. CNA 3 stated she had reheated meal trays in the microwave. CNA 3 stated to check the temperature she just asked the resident if the temperature was okay.
During an interview on 1/26/24 at 1:11 p.m. with Resident 28, with LVN 1 translating, Resident 28 stated when he went to dialysis staff would save his food. Resident 28 stated he did not like it because when he came back from dialysis, the food tasted different. Resident 28 stated the food tasted like it was expired food. Resident 28 stated the CNA would reheat his food. Resident 28 stated when the CNA reheated his food it tasted dry.
During a concurrent observation and interview on 1/26/24 at 1:41 p.m. with Resident 42, with LVN 1 translating, Resident 42 was observed eating food from a styrofoam container. Resident 42 stated when he would go to dialysis, the facility saved his meal tray. Resident 42 stated if he did not want what was on the tray, he would buy something else. Resident 42 stated it was the CNA that warmed his food.
During a review of the Order Listing Report dated 1/26/24, the Order Listing Report indicated, . dialysis for [Resident 28] on Tuesday, Thursday, and Saturday at 6:15 a.m.
During a review of the facility's policy and procedure titled, Cooling and Reheating of Potentially Hazardous or Time/Temperature Control for Safety Food dated 2023, indicated, .Previously cooked PHF (Potentially Hazardous Foods) or TCS (Time/Temperature Safety) food . should be rapidly reheated to an internal temperature of 165 degrees F within two hours. Internal temperature must then register 165 degrees F for fifteen seconds. Be sure the food reaches a full 165 degrees F when reheating .
During a review of professional reference titled, FDA Food Code 2022, section 3-403.11 Reheating for Hot Holding, dated 2022, indicated, . (B) TIME/TEMPERATURE CONTROL FOR SAFETY FOOD reheated in a microwave oven for hot holding shall be reheated so that all parts of the FOOD reach a temperature of at least 74oC [degree Celsius] (165oF) [degrees Fahrenheit] and the FOOD is rotated or stirred, covered, and allowed to stand covered for 2 minutes after reheating .

Based on interview and record review, the facility failed to electronically submit the Payroll-Based Staffing Journal (PBJ - staffing information for all employees in the nursing home based on payroll data submitted on a quarterly schedule) to the Centers for Medicare and Medicaid Services (CMS) for one of four quarters (fourth quarter) in 2023 (July 1, 2023 through September 1, 2023).
This failure had the potential for resident's in the facility to not have staff to resident ratio necessary to provide safe and quality care and prevented the provision of complete and accurate direct care staffing information.
Findings:
During a review of facility's Offsite Prep ([undated] -survey information provided by CMS to review prior to surveying facility). The Offsite Prep indicated, the facility did not submit the PBJ report for the fourth quarter of fiscal year 2023.
During an interview on 1/25/24 at 10:58 a.m. with Director of Nursing (DON), the DON stated she was not responsible for submitting the PBJ report. The DON stated she was aware the PBJ report was not submitted for the fourth quarter of 2023. The DON stated she was aware that the PBJ report needs to be submitted to CMS quarterly. DON stated the Assistant Administrator (AA), was responsible for sending the report. The DON stated if the AA was unavailable the Administrator (ADM), was responsible for sending the report . The DON stated she was aware of the deficient practice if the PBJ report was not submitted to CMS.
During an interview on 1/24/24 at 4:17 p.m.with Administrator (ADM), the ADM stated he was aware the PBJ was not submitted for the fourth quarter, and he was aware. The ADM stated the AA was responsible for sending the PBJ report and the AA had been out of the office for an emergency and he had not been able to speak with him. The ADM stated, when the AA was unavailable the facility hadhad no designated staff member to perform his duties.
A review of CMS' Electronic Staffing Data Submission Payroll-Based Journal: Long-Term Care Facility Policy Manual, Version 2.6., dated June 2022, indicated, .(5) Submission schedule. The facility must submit direct care staffing information on the schedule specified by CMS, but no less frequently than quarterly. Deadline: Submissions must be received by the end of the 45th calendar day (11:59 PM Eastern Time) after the last day in each fiscal quarter in order to be considered timely 2) Uploading data directly from an automated payroll or time and attendance system will function very similarly to how MDS data are submitted currently. The data will be required to meet very specific technical specifications in order to be successfully submitted .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an effective infection prevention and control program when:
1. One of two sampled Licensed Vocational Nurses (LVN 2) tested Resident 18's blood sugar and placed the contaminated (infected by contact) blood glucose (sugar) monitor (glucometer- device that measures blood glucose levels) into the medication cart drawer without being cleaned or disinfected.
This failure had the potential to expose facility residents to blood borne pathogens (infectious microorganisms present in the blood).
2. One of three sampled residents, Resident 32's oxygen (a life-saving colorless, odorless gas) tubing was curled up on the floor.
This failure was a potential trip and infection control hazard for Resident 32.
Findings:
1. During a review of Resident 18's admission Record [AR], undated, the AR indicated, Resident 18 was admitted to the facility on [DATE] with diagnoses which included hemiplegia (paralysis of one side of the body) and hemiparesis (one sided muscle weakness) following cerebral infarction (stroke-blockage in a blood vessel in the brain), Type 2 Diabetes Mellitus (disease in which blood glucose [sugar] is too high) and aphasia (disorder which affects ability to communicate).
During a concurrent observation and interview on 1/24/24 at 11:01 a.m. with LVN 2, LVN 2 walked into Resident 18's room with a lancet (a small blade with a sharp point) and glucometer to test Resident 18's blood glucose. LVN 2 took Resident 18's finger and used the lancet to poke the finger and draw blood. LVN 2 used the glucometer strip in the machine and place the blood on the strip. LVN 2 walked out of the room to the medication cart and opened the top left drawer and placed the glucometer in the drawer, closing it. LVN 2 stated she had forgotten to clean the glucometer prior to placing it in the drawer. LVN 2 stated she should have cleaned the glucometer before placing in the drawer because it was contaminated with germs and blood.
During an interview on 1/25/24 at 10:18 a.m. with the Director of Nursing (DON), The DON stated the nurses were expected to disinfect (to kill germs on surfaces) the glucometer thoroughly prior to putting it into the medication cart. The DON stated it must be cleaned and disinfected for infection control.
During an interview on 1/26/24 at 4:14 p.m. with the Infection Preventionist (IP- professional who make sure healthcare workers and residents are doing all the things they should to prevent infections), the IP stated the nurses should clean and disinfect the glucometers after use for infection prevention. The IP stated he had done spot checks for the nurses on glucometer use, but had no documentation to validate LVN 2 had been observed.
During a review of the facility's document titled Performing Glucometer Check &Cleaning/Disinfecting Glucometer, undated, the document indicated, . (Glucometers should have been cleaned/disinfected before putting them back to med cart) . Glucometer cleaning and disinfecting must be done in between resident's use .
During a review of a professional reference titled, Infection Prevention during Blood Glucose Monitoring and Insulin Administration, dated 3/2011, from the Centers for Disease Control and Prevention (CDC-), the article indicated, . (CDC) has become increasingly concerned about the risks for transmitting hepatitis B (HBV) and other infectious diseases during assisted blood glucose (blood sugar) monitoring . Whenever possible, blood glucose meters should not be shared. If they must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions .
During a review of the manufacturer's instructions the facility provided, the instructions indicated, .Cleaning and disinfecting procedures for the meter . the Evencare G3 Meter should be cleaned and disinfected between each patient .
2. During an observation on 1/22/24 at 9:45 a.m. in Resident 32's room, Resident 32 was observed sitting at bedside with oxygen on via nasal cannula (thin flexible tubing that goes into the nose and is used to provide supplemental oxygen). There was extremely long oxygen tubing coiled up on the floor next to him.
During a review of Resident 32's admission Record [AR], undated, the AR indicated, Resident 32 was admitted to the facility on [DATE] with diagnoses which included chronic respiratory failure (condition in which your blood does not have enough oxygen) and chronic obstructive pulmonary disease (COPD- group of diseases that block airflow and make it difficult to breathe).
During a review of Residents 32's Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], indicated Resident 32's Brief Interview of Mental status assessment (BIMS - assessment of cognitive status for memory and judgement) scored 10 out of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, 00-07 indicates severe impairment). The BIMS assessment indicated Resident 32 had a moderate cognitive impairment.
During a concurrent observation and interview on 1/23/24 at 3:33 p.m. with Resident 32 and Licensed Vocational Nurse (LVN) 1, Resident 32 was observed standing at bedside with the oxygen tubing curled up on the floor at his feet. Resident 32's floor was sticky and LVN 1 stated Resident 32's roommate would spit on the floor frequently. Resident LVN 1 stated Resident 32's tubing was on the soiled floor and could cause an infection control issue and was an accident hazard.
During an interview on 1/25/24 at 4:17 p.m. with the Director of Nursing (DON), the DON stated Resident 32's oxygen tubing should not have touched the floor. The DON stated it was an infection control and safety hazard.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to keep one of three sampled Residents (Resident 1) safe, when Resident 1 eloped [left the facility unsupervised] from the facility and was missing for two hours. The facility failed to follow its policy and procedure titled, Wandering and Elopements, when it did not create a care plan or interventions for wandering/elopement for this resident.
This failure resulted in Resident 1 eloping from the facility, being found two hours later and had the potential to cause harm even death to the Resident 1.
Findings:
During a review of Resident 1's admission Record (AR-provides demographic information, responsible party and contacts financial and insurance) dated 7/28/21, printed at 12:01 p.m., the AR indicated Resident 1 was admitted on [DATE] with primary diagnosis of Acute Respiratory Failure (occurs when the respiratory system is unable to adequately absorb oxygen or excrete carbon dioxide), Chronic Respiratory Failure (ongoing condition that results in the inability to effectively exchange carbon dioxide and oxygen), past history of COVID-19 (A highly contagious respiratory disease caused by the coronavirus, is thought to spread from person to person through droplets), Alcohol abuse (pattern of drinking too much alcohol too often), sacrum fracture (large triangular bone at the bottom of the spine that breaks), left tibia fracture (break in biggest bone between the knee and the ankle), right femur fracture (break in the largest bone in the leg), anxiety disorder (worry and fear do not go away and can interfere with daily activities), and muscle weakness.
During a review of Resident 1's document titled, Admit/Readmit Screener (AS) - V 6 dated 6/3/21, the AS indicated Resident 1 was admitted on [DATE] with an admitting diagnosis of motor accident poor safety awareness. The AS indicated Resident 1 spoke English, .E. Neurological 16. LOC [Level of Consciousness] a. Alert 17. Orientation a. Person b. Place 18. Verbally b. inappropriate . M. Mobility/Safety 43. Mobility 2. Limited assistance b. Walk in corridor: self-performance 2. Limited assistance c. Locomotion on unit: self-performance 2. Limited assistance d. Locomotion off unit: self- performance 2. Limited assistance . i. Gait disturbance/Unsteady gait . R. Evaluation Risk Assessment O. Evaluation of Resident Elopement Risk . 2. Is resident independently mobile? b. Yes 3. Does resident pace, wander, try to get out of door, find family or friend, . b. Yes 4. Does resident have a history of elopement/wandering/getting lost: b. Yes . 6. Based on the above criteria, is this resident at risk for elopement? b. Yes .
During a review of Resident 1's Nurse's Note, dated 7/20/21 at 10:37 p.m., indicated, .resident eloped from facility today. Floor nurses noticed that resident was not in Activity room or Bedroom at around 1900 [7 p.m.]. Floor nurse initiated Facility sweep checking all rooms and bathrooms. Then set 2 CNAs [certified nursing assistants] to look outside of facility, and Hospital next door. When patient was unable to be found, PD [police department] was called along with DON [Director of Nursing], Administrator and DSD [Director of Staff development]. Daughter was called and informed that her father had Eloped the building. Police arrived at 2000 [8 p.m.] face sheet was given and description of resident. Police found resident at around 2015 [8:15 p.m.] and Administrator and DON returned with resident at 2030 [8:30 p.m.]. Skin assessment was completed upon arrival by write rand was showered by 2 CNAs on staff. Resident remains Alert and Confused and stated, I am a grown man and can go anywhere I want. Resident denies pain or any discomfort. Resident is now resting comfortably in bed with one on one Q [every] shift. Call light within reach. Daughter was notified of residents return at 2030 [8:30 p.m.] .
During an interview on 7/28/21, at 11:50 a.m., with the Administrator (ADM), the ADM stated Resident 1 had dementia (impairment of memory and abstract thinking) and sometimes he thought he was in the hospital looking for his mother and his daughter. The ADM stated, We have alarms on our doors, but we don't have wander guard [system using bracelets on residents to be able to track them] set up. They are coming out today or tomorrow to try out the bracelets that go with the alarm system and give us a quote, for now we always have Resident 1 on one-to-one monitoring. The ADM stated, Evidently no one heard the alarm go off based on interviews [with staff]. It is quick [the door alarm] and he [Resident 1] knows how to shut the doors. The ADM stated this was the first time the facility have had a resident elope.
During an interview on 7/28/21, at 2:22 p.m., with the Director of Nursing (DON), the DON stated when Resident 1 was admitted to the facility Resident 1 was recovering from COVID and had been placed on a ventilator (medical device that helps one breathe) during his hospital stay, Resident 1 came to us weak and was not able to get around very well at all. Then Resident 1 had physical therapy and within a couple of weeks Resident 1 became very fast scooting around the facility in his wheelchair. Resident 1 remained confused asking for his mother and daughter. The DON stated it became a weekly occurrence for him to be looking for his daughter, he would set off the alarm on the door, but he never got outside until this time. The DON stated Resident 1's wandering should have been addressed sooner, the facility has a wander guard system partially set up and we are working on getting the system working to help prevent and track residents when this happens.
During a concurrent interview and record review on 7/28/21, at 2:30 p.m. with the DON, Resident 1's Care Plan titled, Wandering/Elopement, date initiated 7/20/21, was reviewed. The Care Plan indicated, it was initiated on 7/20/21, the DON stated this was the only care plan for wandering that Resident 1 hand it should have been initiated sooner.
During an interview on 7/28/21, at 2:40 p.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 1 was one of her residents that she cared for on 7/20/21 but the elopement occurred after her shift was over. CNA 1 stated she was familiar with Resident 1 and there were days when he will try multiple doors to get out and once, he gets one open he is fast and books it.
During an interview on 7/28/21, at 4:28 p.m., with CNA 2, CNA 2 stated she was working on 7/20/21 when Resident 1 eloped. CNA 2 stated she last saw Resident 1 at 6 p.m. sitting in his wheelchair in his room eating his dinner. CNA 2 stated Resident 1 had opened the door over 30 times and had gotten out of the building before, she had to stop him before and brought him back inside. CNA 2 stated, this happens quite a bit [Resident trying to leave the facility]. CNA 2 stated the facility had door alarms that go off when the door was opened but she did not recall if she heard one go off when Resident 1 eloped on 7/20/21.
During a review of the facility's policy and procedure titled, Wandering and Elopements dated 3/2019, indicated, .The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. Policy Interpretation and Implementation 1. If identified as at risk for wandering, elopement, or other safety issue, the resident's care plan will include strategies and intervention to maintain the resident's safety .
During a review of a professional reference titled, Wandering and Elopement, dated 2023 retrieved from Nursing Home Alert at https://www.nursinghomealert.com/wandering-and-elopement, indicated, .If a long-term care facility resident who is not capable of protecting him or herself from harm or who is cognitively impaired wanders or leaves the nursing home (elopes) and gets hurt, the facility may be acting negligently and is responsible for the resulting harm. Wandering and elopement are defined as: Wandering: cognitively impaired resident can move about inside the facility without an appreciation of personal safety needs and possibly enter into harm's way. Elopement: residents who are incapable of protecting themselves from harm are able to successfully leave the facility unsupervised and unnoticed and possibly enter into harm's way. Wandering and elopement can result in serious injury and even death. Ways to help prevent wandering and elopement include: Behavioral intervention; Family and staff education; Installing alarms on exit doors; Instituting a missing persons protocol; Locking systems; Patient tracking devices such as the Wanderguard bracelet that alerts staff when a resident exits the facility; Performing a resident risk assessment; Posting photographs of residents who wander or are at risk for elopement at the front door; Providing enclosed outdoor spaces; Supervised walks .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to protect the rights of one of three residents (Resident 1), when Resident 1 asked to be sent to the hospital for worsening of his sinus issues and the licensed nurse (LVN 1) told him he had two options: one wait for the doctor to come in and assess him or leave to go to the hospital by himself against medical advice (AMA).
This failure resulted in Resident 1 getting upset and feeling like he was not being treated appropriately so he left in his wheelchair (WC) and wheeled himself to the Emergency Department (ED) of the hospital next door. Resident 1 was admitted to this hospital with Sinusitis (sinus infection) and placed on antibiotics (medication used to treat infections) and prednisone (steroid used to decrease swelling).
Findings:
During an interview on 7/28/21, at 9:10 a.m., with Resident 1, Resident 1 stated he was a resident at this facility, and he did not receive proper care and treatment. Resident 1 stated on 7/20/21 he asked licensed vocational nurse (LVN) 1 to send him back to the hospital and she refused to call an ambulance for him and told him if I didn't like it, I could call an ambulance myself, but she also mentioned I could leave AMA [against medical advice] if I choose to and I left. She asked me to sign the paperwork [for the AMA] and I refused. Resident 1 stated he used his WC and wheeled himself to the Emergency Department (ED) in the hospital next door in the Summer when the temperature was at least 100 degrees Fahrenheit (unit of measurement) outside. Resident 1 stated he was seen by the medical doctor in the ED who did a CT scan (computerized tomography scan is a series of images taken of the sinuses) and started him on antibiotics and prednisone. Resident 1 stated the hospital admitted him and he was discharged on 7/25/21.
During a review of Resident 1's Hospital Discharge Summary (DS), dated 7/25/21, the DS indicated Resident 1 was admitted on [DATE] at 2:06 p.m., Reason for admission: acute sinusitis Final Diagnosis: acute sinusitis . Hospital Course [AGE] years old gentleman with past medical history of chronic sinusitis who was on maintenance steroids . who presented with worsening of his sinusitis symptoms for the past week. He complains headache and retroorbital pain that is worse when he beds over, also this has also accompanied by sinus drainage. He complains of fatigue feeling tired. Denied fever chills nausea or vomiting. During course of hospitalization, he received prednisone and antibiotics. The symptoms improved to his baseline. Patient functional status is at his baseline he is wheelchair bound . The DS indicated discharge date [DATE] at 11:06 a.m.
During a review of Resident 1's admission Record (AR- document that provides name, date of birth , admission date, contact information, insurance, and diagnosis information) for the facility, dated 7/29/23, the AR indicated Resident 1 was admitted on [DATE] with the following diagnoses: congestive heart failure (CHF- condition in which your heart cannot pump blood well enough to meet your body's needs), acute respiratory failure (comes on quickly a disease or injury that affects your breathing), diabetes type 2 (problem in the way the body regulates and uses sugar as a fuel in the body), atrial fibrillation (an irregular and often very rapid heart rate), major depressive disorder (persistent depressed mood and long-term loss of pleasure or interest in life), chronic sinusitis (swelling of the sinus or nasal passages occurring for more than 12 weeks at a time), morbid obesity (chronic disease causing too much body fat that interferes ones health), and osteoarthritis (breakdown of joint cartilage and the underlying bone, causing pain and stiffness) bilateral (both) knees.
During a review of Resident 1's Admit/Readmit Screener -V 6 form (ARS form- first full assessment of resident when admitted to a nursing facility), dated 2/1/21, the ARS form indicated this was a new admission for Resident 1, Resident 1 was English speaking; under section E. Neurological 16. LOC (level of consciousness) marked as alert 17. Oriented to a. Person b. Place c. Time d. Situation 18. Verbally resident is Appropriate. Resident 1's ARS form indicated under section M. Mobility/Safety 43. Mobility d. Locomotion off unit: self-performance 1. Supervision f. [NAME] g. Wheelchair (manual or electric).
During a review of Resident 1's Nurse's Note, dated 7/20/21 at 9:19 a.m., the note indicated, . Resident [Resident 1] stated I am going to go to the emergency room to seek medical attention because he is sick and he believes we are not giving him the medical attention that he needs, this writer [Licensed Vocational Nurse - LVN 1] advised him that he was sent to [name of hospital] last week because he stated the same thing, if the ER doctor did not felt that he needed antibiotics which the resident stating that he needs. I can't give him anything else but the medication he has prescribed at this time. He state no I got discharge instruction to return if not feeling better writer advised him that is routine instructions for every patient that goes to the ER he can call a friend or relative to take him for an appointment if he likes or he can sign (AMA), he refused to sign against medical advice, but he decided to elope [leave the facility] and he left the building on his wheelchair with his laptop and other personal belongings. DON [Director of Nursing], DSD [Director of staff development], and Administrator aware .
During an interview on 3/16/22, at 3:05 p.m., with LVN 1, LVN 1 stated she took care of Resident 1 on 7/20/21. LVN 1 stated that day Resident 1 came up to her in his WC and told her he needed his antibiotics and his prednisone, and she stated she could not prescribe those and explained that he had just gone to the ED approximately a week ago and they [the hospital] sent him back. LVN 1 stated Resident 1 did not want to be seen by the facility's doctor (Medical Doctor - MD 1), she stated that she called MD 1 to let him know what the resident was requesting. LVN 1 stated MD 1 told her Resident 1 could wait until the MD came in to see him or he could be sent to the hospital. LVN 1 stated she had discussed Resident 1's request with the ADM (Administrator) and the DON and then told him he could call a friend or relative to help him set up an appointment and help with transportation or he could leave AMA. LVN 1 stated Resident 1 left AMA and refused to sign the AMA form. LVN 1 stated, I don't know, when asked why she did not set up transportation for Resident 1.
During an interview on 3/15/22, at 11:31 a.m., with the DON, the DON stated if LVN 1 called MD 1, MD 1 always sent the residents out to the ED even if it is something small and the residents wanted to be seen. The DON stated she was not sure why this was not done for Resident 1.
During a review of the facility's Policy and Procedure titled, Resident Rights, dated 12/2016, indicated, . Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation 1. Federal and state laws guarantee certain basic right to all residents of this facility. These rights include the resident's right to: a. a dignified existence; b. be treated with respect, kindness, dignity; c. be free from abuse, neglect, misappropriation of property, and exploitation; . e. self-determination; f. communication with and access to people and services, both inside and outside the facility; g. exercise his or her rights as a resident of the facility and as a resident or citizen of the United States; h. be supported by the facility in exercising his or her choice in accordance with state law .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents who use psychotropic (drug that effects brain activity) medications receive a Gradual Dose Reduction (GDR - tapering of dose to determine if symptoms can be managed at a lower dose or discontinued), for one of sixteen sampled residents (Resident 114).
This failure placed Resident 114 at risk for prolonged use of psychotropic medication and increased risk for adverse medication side effects.
Findings:
During an observation, on [DATE] at 9:30 a.m., Resident 114 was asleep in her bed.
During an observation, on [DATE] at 11:00 a.m., Resident 114 was asleep in her bed with the blanket over her head.
During a concurrent observation and interview with Licensed Vocational Nurse (LVN) 2, on [DATE] at 1:30 p.m., Resident 114 was asleep in her bed. LVN 2 stated Resident 114 had gotten up to eat but went back to bed. LVN 2 stated Resident 114 occasionally slept all day due to her diagnosis of sleep disorder about one time per week.
During an observation, on a[DATE] at 10:38 a.m., Resident 114 was observed walking around facility. Resident 114 was confused and was not interviewable.
During a concurrent interview and record review, on [DATE] at 8:51 a.m., with the Director of Nurses (DON), the Physician's Orders (PO) and MAR for Resident 114 were reviewed. The DON stated Resident 114 had received Olanzapine (medication for psychosis (hallucinations) 10 milligrams (mg-weight measurement) daily and Valproic acid (mood stabilizer) 125 mg twice a day since admission [DATE]. The DON stated the facility had not tried a GDR on either of the psychotropic medications since admission. The DON stated Resident 114 had behaviors of screaming, hitting herself, hallucinations and elopement. The DON was not able to state how frequent the hallucinations were because the behavioral data reports she reviewed on the electronic documentation record indicated 0. A Review of the Pharmacist Consultant reports dated 5/21-9/21 did not indicate a GDR was recommended. The DON stated the facility had not done a GDR for Resident 114 but should have. The DON stated the facility's PC should have monitored antipsychotic medications for Resident 114 but had not. The DON stated the current policy for Antipsychotic Medication dated 3/15 did not indicated a time frame for the GDR process or the steps to be followed for monitoring antipsychotic medications. The DON stated the GDR was supposed to be reviewed every 30 days and a reduction should be done. The DON stated she was not sure how often GDR was supposed to be done. The facility should have had someone assigned to monitor the GDRs were done but had not.
During a concurrent interview and record review, on [DATE] at 10:09 a.m., with the Registered Nurse Consultant (RNC), the RNC stated the facility had not done a GDR for Resident 114. The RNC stated the PC had not been monitoring the behavioral data for Resident 114 but should have. The RNC stated the behavioral data was incorrect because the charting system was set up wrong and not a tally system. The RNC stated the PC should have monitored the effectiveness of the psychotropic medications but had not. The RNC stated, .If the PC had monitored the behaviors, we would not have missed the psychotropic medication GDR .
During a concurrent interview and record review, on [DATE] at 11:32 a.m., with the Social Services Director (SSD), the SSD reviewed the MAR's dated 5/21-10/21 for Resident 114 and stated there was no GDR since admission 5/21. The SSD stated the behavioral data should have been tallied and brought up in Interdisciplinary Team (IDT) meetings but was not. The SSD stated it was the responsibility of the DON to ensure GDRs were done. The SSD stated when a resident was admitted on an antipsychotic medication, nursing was responsible for monitoring daily, the MD and PC were supposed to monitor monthly, and the IDT was to monitor quarterly and as needed but that had not happened. The SSD stated the MD and PC needed a behavior number to make recommendations for medication reduction but it was not available. The SSD stated the facility was required to evaluate residents for a GDR but had not. The SSD stated Resident 114 could have been overmedicated, slept all the time, or died if their psychotropic medications were not monitored.
During an interview, on [DATE] at 11:59 a.m., with the Administrator (ADM), the ADM stated there was no behavioral data available for Resident 114 due to the way it was charted into the facility's electronic charting system. The ADM stated the facility had not assigned anyone to collect the behavioral data for the MD and PC monthly medication reviews. The ADM stated If the MD was not given behavioral data, he would not know how effective the medication was or the resident could have been left on a medication for longer than needed.
A copy of Resident 114's Physician's Orders was requested on Friday [DATE] about 4:30 p.m. from the DON but was not provided. On Monday [DATE] at 8:30 a.m., the DON brought Resident 114's Physician's Orders with the changes made to the psychotropic medication on Sunday [DATE]. Both psychotropic medications, Olanzapine and Valproic Acid were reduced by half on Sunday [DATE].
During a concurrent phone interview and record review on [DATE] at 1:47 p.m., with the PC, the monthly pharmacy audit reports for 5/21-9/21 were reviewed. The PC stated there had been no GDR for psychotropic medication done for Resident 114. The PC stated she was responsible to review antipsychotic medications every month for Resident 114. The PC stated she had just started and [DATE] was her first visit to the facility. The PC stated she was responsible for looking at behavioral data monthly but had not due to the data collection system at the facility. The PC stated she had told the DON the facility needed to get a number as opposed to a yes or no question for behavior data collection. The PC stated she would not be able to recommend any changes to psychotropic medications without a behavior frequency number. The PC stated the residents may have increased chance of adverse drug effects if GDR were not done. The PC stated there should be 2 GDR attempts or contraindications documented per quarter but there was not. The PC stated Resident 114 should have had a GDR by 8/21 because she was admitted 5/21. The PC stated she had noticed there were some inconsistencies in monitoring behaviors at the facility, but the previous PC had not corrected the issue. The PC stated she was not consulted by the DON on [DATE] for a psychotropic medication reduction with the Physician. The PC stated she would not have recommended both medications [Olanzapine and Valproic Acid] were reduced at the same time and not by half. The PC stated this was not a gradual reduction.
During a review of Resident 114's Face Sheet dated [DATE], the Face Sheet indicated the admission date was [DATE]. The Face Sheet indicated Resident 114 had diagnosis of Dementia (memory impairment), Bipolar Disorder (mental condition marked by periods of elation and depression), Major Depressive Disorder (chronic loss of interest/sadness), Psychotic Disorder (chemical imbalance in the brain marked by seeing or hearing things that are not there), Circadian Sleep Disorder (unable to sleep at regular times), Muscle Wasting (weakness and shrinking in the muscles), and Hypertension (higher than normal pressure in the blood vessels).
During a review of Resident 114's MARs dated [DATE]-[DATE], the MAR's indicated, .Olanzapine: Monitor for Episodes of Restlessness .If Behavior noted choose chart code 12 [Yes] .If no behavior noted choose chart code 2a [No] .Olanzapine Tablet 10 mg Give 1 tablet by mouth one time a day for Psychosis .Valproic Acid 250 mg/5ml give 2.5 ml by mouth two times a day for Bipolar Disorder .
During a review of the facility's policy and procedure titled, Antipsychotic Medication Use dated 3/2015, the policy indicated, .Antipsychotic medications will be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reduction .
During a review of the facility's policy and procedure titled, Pharmacy Services Overview dated 4/2019, the policy indicated, .Pharmacy services consist of .Monitoring responses to . All medications .The process of identifying, evaluating and addressing medication related issues .

Based on observation, interview and record review, the facility failed to store drugs and biologicals according to professional standards of practice and facility policy and procedure when a multi-dose vial of tuberculin (TB) testing serum (injected under the skin to test for tuberculosis (infectious bacterial disease characterized by nodules in the tissue and lungs) opened 8/21/21 and expired 9/20/21 was in the refrigerator area designated for use; and a 1 liter bottle of [Brand 1.5] gastrostomy tube (tube surgically inserted in the abdomen for access to the stomach) enteral feeding formula which had expired 6/21 (expired 4 months prior) was on the shelf with other formulas designated for resident use; and 16 bottles of expired enteral feeding [Brand 1.0] and 6 bottles of expired enteral feeding [Brand 1.2] were stored inside the dry food storage room. The facility did not implement a system to routinely monitor the medication storage room for expired products.
These failures had the potential to affect 16 of 16 sampled residents and 15 unsampled residents if medications and feeding formulas were not routinely checked for expiration dates and were used or consumed which placed the health and safety of all residents at risk.
Findings:
During the initial tour of the with Dietary Manager (DM) 2, on 10/5/21, at 8:50 a.m., 16 bottles of enteral feeding [Brand 1.0] with an expiration date of 10/1/21 and six bottles of enteral feeding [Brand 1.2] with an expiration date of 8/1/21 were stored inside the kitchen dry food storage room. The DM 2 validated the 16 bottles of enteral feeding [Brand 1.0] and 6 bottles of enteral feeding [Brand 1.2] were all expired and would be discarded.
During a concurrent observation and interview, on 10/6/21 at 9:18 a.m., the facility's medication storage room was observed with Licensed Vocational Nurse (LVN) 4. LVN 4 stated the facility had only one medication storage room. One 1-liter bottle of tube feeding formula was on the lowest shelf with all the other brands of feeding formulas. The feeding formula label indicated the expiration date was 6/21. LVN 4 stated the formula had expired close to 4 months ago and should have been discarded and not stored on the shelf for use. LVN 4 stated the expired formula could have made someone sick or caused vomiting and diarrhea if it had been used after the expiration date. One 5 milliliter (ml-volume measurement) of TB testing serum was on the center shelf of the medication storage refrigerator and available for use. The TB serum had a blue label that indicated the bottle was opened on 8/21/21 and was to be discarded by 9/20/21. LVN 4 stated the TB serum should have been discarded. LVN 4 stated expired medications and formulas were supposed to be discarded and not on the shelves. LVN 4 stated the expired TB serum would not give an accurate TB test if it had been used after expiration date. The TB serum manufacturer's label indicated, once the bottle had been opened, it was to be discarded after 30 days. LVN 4 stated The LVN's were responsible for auditing the medication storage room one time per week when they had time. LVN 4 stated there was no assignment sheet to see who was responsible for the medication room audits. LVN 4 stated there were no documented medication storage audits. LVN 4 stated the LVN's were supposed to look at all the medication, feeding formulas, and injectable medications in the refrigerator once a week but had not. LVN 4 stated the nurses used to fill out a sheet when the audit was done to make sure everything was checked but had not used the form in a long time. LVN 4 stated the Director of Nurses (DON) was responsible for monitoring the LVNs did their job. LVN 4 stated and she did not know how the DON was able to monitor the audit were done when there was no document to look at.
During a concurrent interview and record review, on 10/6/21 at 9:53 a/m., with the DON, the facility's policy titled, Storage of Medications dated 10/8/20 was reviewed. The DON stated the facility was not supposed to have expired TB serum in the refrigerator or expired feeding formulas on the shelves for use. The DON stated the LVN's were responsible for checking the medication storage for expired medications and formulas every Sunday. The DON stated the LVN's were not aware there was a log for the medication room storage audit. The DON stated there was no documentation of the LVN assignment to audit the medication storage room. The DON stated there was no documentation of the medication storage room audits. The DON stated the expired TB serum should have been discarded 9/20/21. The DON stated the TB serum would have not given an accurate TB test had it been used. The DON stated the medication storage policy currently used at the facility did not indicated the procedure for monitoring for expired medications. The DON stated she would have the Director of Staff Development work on the medication storage policy to include the procedure for monitoring expired medication and formulas. The DON stated she was responsible for monitoring the LVN's did the medication storage audit. The DON stated she should have given the LVN's an in-service on the medication storage room audits and the log but had not.
During a concurrent phone interview and record review on 10/12/21 at 1:47 p.m., with the Pharmacist Consultant (PC), the monthly facility reports for 5/21-9/21 were reviewed. The PC stated she had just started and 9/8/21 and was her first visit to the facility. The PC stated she had not had time to look at the medication storage room. The PC stated the facility should have used a medication storage audit log with instructions. The PC stated expired TB serum and feeding formulas should have been discarded. The PC stated the TB serum would not have been effective in detecting a TB infection. The PC stated the feeding formula would have caused stomach upset, vomiting, and diarrhea.
During a review of the facility's policy and procedure (P&P) titled, Food Storage, dated 5/1/2020, the P&P indicated, Policy: .Dry Goods Storage Guidelines .Do check expiration dates on boxes of foods to be sure the length of time is correct .
During a review of the facility's policy and procedure titled, Storage of Medication dated 10/8/20, the policy indicated, .The nursing staff is responsible for maintaining medication storage .Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed .Drugs shall not be kept in stock after the expiration date .

Based on observation, interview, and policy and procedure review, the facility failed to ensure the kitchen staff had the appropriate skill set to prepare meals served to the facility residents when one [NAME] (Cook 1) did not follow the facility menu, did not calibrate a food thermometer correctly, did not take food temperatures correctly, and did not know the correct thawing procedure when using the sink thawing method for meats.
These failures had the potential to place the 31 residents who received food prepared in the kitchen at risk for foodborne illness and to not meet their nutritional needs which could lead to nutritional related health concerns.
Findings:
1a. Review of the job description for the [NAME] position, signed and dated 3/14/21 by the [NAME] 1 showed, the cook position was responsible for checking the menu and production sheet for the meal, and lunch and dinner meal preparation.
Review of a type-written letter signed by the RD 1 on 10/5/21 at 12:17 p.m., showed the high calorie, high protein diet (HiCal/Pro) was interchangeable with the large portion diet.
Review of the facility document titled Diet Spreadsheet, Fall/Winter 2 undated, showed for Wednesday, HiCal/Pro diets should have received three ounces pit ham, half cup of corn souffle, half cup of roasted zucchini and red peppers, two dinner rolls, 2 packets of margarine, half cup of spiced apricots and eight ounces of whole milk.
During an observation of the lunch meal tray line on 10/6/21 at 11:42 a.m., with the [NAME] 1, the Hical/Pro and large portion diets were served 1 ½ servings of a three-ounce slice of ham, half cup of corn souffle, half cup of roasted zucchini and red peppers, one slice of bread, half cup of spiced apricots and eight ounces whole milk. Purée Hical/Pro diets were served two #8 scoops of puree ham with gravy, half cup of puree corn, half cup of puree zucchini, puree bread, half cup of puree apricots and eight ounces milk.
On 10/6/21 at 1:23 p.m., an interview was conducted with the [NAME] 1. The [NAME] 1 stated for HiCal/Pro diets he gave an extra three ounces of ham. For large portion diets, the [NAME] 1 stated he gave an extra half scoop of all food items on the tray.
On 10/07/21 at 9:31 a.m., an interview was conducted with the RD 1. The RD 1 stated HiCal/Pro diets should receive a large portion of the entrée and a double serving of bread. The RD 1 further stated the HiCal/Pro diet is comparable to the large portion diet. Cross reference to F 803, example #1.
Review of the facility document dated 7/13/21, titled In-service showed, the topics discussed included reading spreadsheets. The document showed the [NAME] 1 was in attendance.
b. Review of the job description for the [NAME] position, signed and dated 3/14/21 by the [NAME] 1 showed, the cook position was responsible for checking the menu and production sheet for the meal, and lunch and dinner meal preparation.
Review of the facility document titled Diet Spreadsheet, Fall/Winter 2 undated, showed for Wednesday, Regular, pureed, LCS (low concentrated sweets), small portions and soft diets were to receive one packet of margarine and HiCal/Pro diets were to receive two packets of margarine.
During an observation of the lunch meal tray line on 10/6/21 at 11:42 a.m., with the [NAME] 1, no margarine was observed on any lunch meal trays.
On 10/6/21 at 1:30 p.m., an interview was conducted with the Diet Aide (DA) 2. The DA 2 confirmed margarine was not provided on the lunch meal trays. The DA 2 stated the CNAs were responsible for putting margarine on the meal trays.
On 10/6/21 at 1:39 p.m., an interview was conducted with the CNA 3. The CNA 3 stated she does not add margarine to meal trays unless the resident asked for it.
On 10/08/21 at 10:06 a.m. an interview was conducted with the [NAME] 1. The [NAME] 1 stated it was his responsibility to ensure meal trays were correct. The [NAME] 1 stated the Diet Aide should put margarine on the meal trays during meal tray line. Cross reference to F 803, example #2.
Review of the facility document dated 7/13/21, titled In-service, showed the topics discussed included reading spreadsheets. The document showed the [NAME] 1 was in attendance.
c. Review of the facility Policy and Procedure titled, Food Service and Temperature Control, dated 5/1/2020 showed, 2. He/she shall use the appropriate metal stem-type numerically sealed food service thermometer, calibrated to an accuracy of plus or minus 2 degrees Fahrenheit (F).
Review of the facility document titled Ice Bath Thermometer Calibration, undated, showed:
1. Fill a cup with ice. Fill the cup all the way to the tope with ice. 2. Add correct amount of water.
2. Add correct amount of water. Fill the cup about ½ inch below the top of the ice. Ice should not be floating on the bottom. If you see the ice starting to float off the bottom of the cup, pour out some of the water
3. Insert probe, gently stir. Stir the probe in the vertical center of the ice. Allow enough time for the thermometer reading to stabilize. Stirring allows the ice to move past the probe and not rest on it, which could give an inaccurate reading. Do not let the probe rest against the sides or bottom of the cup.
Review of the facility document titled Verification of Job Competency Demonstration-Diet Aides dated 11/6/2020 for the [NAME] 1 showed, the [NAME] 1 was competent in the food thermometer calibration and recording process.
On 10/6/21 at 9:43 a.m. an observation of the food thermometer calibration and concurrent interview was conducted with the [NAME] 1. The [NAME] 1 stated he calibrated the food thermometer prior to each meal. The [NAME] 1 used an eight-ounce cup filled halfway with ice. The [NAME] 1 stated he added hot water to the cup to melt the ice. The [NAME] 1 inserted the food thermometer into the ice/water mixture with the food thermometer probe touching the bottom of the cup. When asked if the [NAME] 1 had received any training on food thermometer calibration, the [NAME] 1 stated he referred to the posted instructions.
On 10/08/21 at 3:48 pm an interview was conducted with the RD 1 and the DM 2. Both the RD 1 and DM 2 stated the cook should know the appropriate technique to calibrate a meal thermometer using the ice bath method.
Review of the facility document dated 7/20/21, titled In-service showed the topics discussed included thermometer calibration. The document showed the [NAME] 1 was in attendance.
d. Review of the facility Policy and Procedure titled, Food Service and Temperature Control, dated 5/1/2020 showed, 3. Using a calibrated food thermometer, obtain final temperatures for all menu items .Insert the thermometer into the uppermost portion of the product on the steam table in order to obtain the temperature. Care must be taken to avoid placing the thermometer on the side or the bottom of the product, touching the pan.
Review of the job description for the [NAME] 1 signed and dated 3/14/21 showed, the cook position was responsible for taking temperatures of the dinner meal.
According to the USDA Food Code Annex 2017, Section 4-302.12 Food Temperature Measuring Devices, when determining the temperature of thin foods, those having a thickness of less than ½ inch, it is particularly important to use a temperature sensing probe designed for that purpose. Bimetal, bayonet style thermometers are not suitable for accurately measuring the temperature of thin foods such as hamburger patties because the large diameter of the probe and the inability to accurately sense the temperature at the tip of the probe.
During an observation of the final cooking temperature of ham for the lunch meal service and concurrent interview with the [NAME] 1 on 10/6/21 at 11:30 a.m., the [NAME] 1 removed a large pan covered with foil from the oven. The [NAME] 1 inserted a food thermometer through the foil into the food item. The [NAME] 1 was asked to remove the foil from the pan. The pan contained cooked ham sliced less than half an inch in thickness. The sliced ham was arranged with more than three slices on top of each other in the pan. The [NAME] 1 proceeded to insert the food thermometer into several pieces of sliced ham at the same time.
On 10/08/21 at 3:48 pm an interview was conducted with the RD 1 and the DM 2. Both the RD 1 and DM 2 stated the cook should know the appropriate technique for taking temperatures of food prepared in the kitchen.
e. According to the USDA Food Code 2017, Section 3-501.13 Thawing, Time/Temperature Control for Safety Food shall be thawed: B. Completely submerged under running water: 1. At a water temperature of 70 degrees F or below .
Review of the facility document titled Verification of Job Competency Demonstration-Diet Aides dated 11/6/2020 for the [NAME] 1 showed, the [NAME] 1 was competent in thawing meats and foods, state preferred method and a quick method, storage.
On 10/06/21 at 8:52 a.m. an observation of turkey meat thawing under running water in a sink located in the kitchen and concurrent interview with the [NAME] 1 was conducted. The temperature of the water was 78 degrees F using the surveyor thermometer. The [NAME] 1 stated the water temperature for thawing meat in the sink should be 41 degrees F. When asked if using water with a temperature of 78 degrees F was appropriate to thaw meat, the [NAME] 1 stated he was not sure.
On 10/08/21 at 3:48 pm an interview was conducted with the RD 1 and the DM 2. Both the RD 1 and DM 2 stated meats thawed using the sink thawing method must be thawed appropriately using water 70 degrees F or less.
Review of the facility document dated 3/23/21, titled In-service, showed topics discussed included thawing of meat. The document showed the [NAME] 1 was in attendance.
On 10/08/21 at 10:06 a.m. an interview was conducted with the [NAME] 1. The [NAME] 1 stated he was promoted to the cook position in 12/2020. He stated he was trained by the [NAME] 3 for one and a half weeks.
On 10/08/21 at 10:47 a.m. an interview was conducted with the [NAME] 3. The [NAME] 3 stated she trained the [NAME] 1. The [NAME] 3 stated she trained the [NAME] 1 how to follow recipes and diet spreadsheets, how to calibrate a thermometer, how to take food temperatures and thawing meat using the sink thawing method.

Based on observation, interview and record review, the facility failed to ensure the facility menus were followed when:
1. High Calorie/High Protein (HiCal/Pro) diets were not followed for one sampled resident (Resident 112) and one nonsampled resident (Resident 115) out of 31 residents and,
2. The diet spreadsheet was not followed for all diets served in the facility.
These failures posed the risk for 31 residents who received food prepared in the kitchen to not meet their nutritional needs.
Findings:
1. Review of a type-written letter signed by the RD 1 on 10/5/21 at 12:17 p.m., showed the HiCal/Pro diet was interchangeable with the large portion diet.
Review of the facility document titled Diet Spreadsheet, Fall/Winter 2 undated, showed for Wednesday, HiCal/Pro diets should have received three ounces pit ham, half cup of corn souffle, half cup of roasted zucchini and red peppers, two dinner rolls, 2 packets of margarine, half cup of spiced apricots and eight ounces of whole milk.
During an observation of the lunch meal tray line on 10/6/21 at 11:42 a.m., with the [NAME] 1, the Hical/Pro and large portion diets were served 1 ½ servings of a three-ounce slice of ham, half cup of corn souffle, half cup of roasted zucchini and red peppers, one slice of bread, half cup of spiced apricots and eight ounces whole milk. Purée hical/pro diets were served two #8 scoops of puree ham with gravy, half cup of puree corn, half cup of puree zucchini, puree bread, half cup of puree apricots and eight ounces milk.
On 10/6/21 at 1:23 p.m., an interview was conducted with the [NAME] 1. The [NAME] 1 stated for HiCal/Pro diets he gave an extra three ounces of ham. For large portion diets, the [NAME] 1 stated he gave an extra half scoop of all food items on the tray.
On 10/07/21 at 9:31 a.m., an interview was conducted with the RD 1. The RD 1 stated HiCal/Pro diets should receive a large portion of the entrée and a double serving of bread. The RD 1 further stated the HiCal/Pro diet is comparable to the large portion diet.
2. Review of the facility document titled Diet Spreadsheet, Fall/Winter 2 undated, showed for Wednesday, Regular, pureed, LCS (low concentrated sweets), small portions and soft diets were to receive one packet of margarine and HiCal/Pro diets were to receive two packets of margarine.
During an observation of the lunch meal tray line on 10/6/21 at 11:42 a.m., with the [NAME] 1, no margarine was observed on any lunch meal trays.
On 10/6/21 at 1:30 p.m., an interview was conducted with the Diet Aide (DA) 2. The DA 2 confirmed margarine was not provided on the lunch meal trays. The DA 2 stated the CNAs were responsible for putting margarine on the meal trays.
On 10/6/21 at 1:39 p.m., an interview was conducted with the CNA 3. The CNA 3 stated she does not add margarine to meal trays unless the resident asked for it.
On 10/08/21 at 10:06 a.m. an interview was conducted with the [NAME] 1. The [NAME] 1 stated it was his responsibility to ensure meal trays were correct. The [NAME] 1 stated the Diet Aide should put margarine on the meal trays during meal tray line.

The facility failed to ensure one of 16 sampled residents' (Resident 118) food preferences were honored when:
Resident 118 did not receive cranberry juice with her lunch meal as she requested. Resident 118 received milk with her lunch meal after informing the facility she did not like milk.
This failure caused Resident 118 to not receive the beverage she preferred.
Findings:
During the lunch meal observation on 10/5/21 at 12:08 pm. Resident 118 complained she never received the cranberry juice she requested with her meals. Her lunch meal did not include cranberry juice on her tray but rather included an 8 oz glass of milk for the beverage. Resident 118 stated she did not like milk but received it with her meals.
On 10/5/21 at 12:20 p.m. an interview was conducted with the DSD. The DSD confirmed Resident 118 received milk with her lunch meal and did not receive cranberry juice.
Review of Resident 118 meal ticket showed for beverages: 4 ounces cranberry juice and for dislikes: milk to drink.
On 10/08/21 at 3:48 p.m., an interview with conducted with the RD 1 and the DM 2 regarding resident preferences. Both the RD 1 and DM 2 stated resident preferences should be followed.

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary conditions were followed in the kitchen when:
1. Proper procedures were not followed for cooling ambient (foods prepared at room temperature) foods.
2. The ice machine drainpipe located in the SNF supply room did not have an air gap.
3. The can opener blade was dirty.
These failures had the potential to place the 31 residents who received food prepared in the facility kitchen at risk for foodborne illness.
Findings:
1. On 10/6/21 at 3:41 p.m. an interview was conducted with the [NAME] 2 and the DM 2 regarding the preparation of tuna salad. The [NAME] 2 stated the cans of tuna were stored in the storeroom. The [NAME] 2 stated once the tuna salad was mixed with the mayonnaise and other ingredients, she took the temperature and wrote the temperature on a piece of paper. The [NAME] 2 then put the tuna salad in the refrigerator. Half an hour before meal service, the [NAME] 2 took the temperature of the tuna salad and records that in the logbook. The DM 2 was unable to confirm any recorded temperatures in the logbook for tuna salad. The DM 2 stated the kitchen did not utilize a cooling monitoring form. The DM 2 further stated cans of tuna should be stored in the refrigerator.
On 10/6/21, at 3:47 p.m., an interview was conducted with the DA 1. The DA 1 stated, she was preparing a vegetable salad for dinner. The DA 1 stated the salad recipe included green beans, carrots, mayonnaise, and sour cream. The DA 1 stated she mixed all the ingredients together at room temperature and put the salad in the walk-in refrigerator. The DA 1 stated, she would take the salad temperature before serving [for consumption of residents]. The DA 1 stated, she did not take the temperature of the salad after mixing or before putting the salad inside the refrigerator.
On 10/6/21 at 3:49 p.m. the vegetable salad was observed in the walk-in refrigerator. The temperature of the salad was 49.8 degrees F (Fahrenheit). Cooked carrots were observed on ice on the counter in the kitchen. The DA 1 stated the carrots were for the salad. The DA 1 confirmed there had not been any time or temperature monitoring of the carrots.
During an interview on 10/7/21, at 11:30 a.m., with the RD 1 and the DM 2, both RD 1 and DM 2 stated, a temperature log for ambient foods was required. Both RD 1 and DM 2 stated, food served outside of acceptable temperature range could place residents at risk for foodborne illness.
According to the USDA Food Code 2017, Section 3-501.14 Cooling, (B) Time/temperature control for safety food shall be cooled within 4 hours to 41 degrees F or less if prepared from ingredients at ambient temperature, such as reconstituted foods and canned tuna.
2. During a concurrent observation and interview on 10/5/21, at 10:10 a.m., with the Maintenance Staff (MAINS) 1, in the SNF Supply Room, the ice machine drainpipe was observed below the flood level rim of the floor sink. The MAINS 1 confirmed there was not an air gap on the ice machine drainpipe.
During an interview on 10/7/21, at 11:30 a.m., with the RD 1 and the DM 2, both the RD 1 and the DM 2 stated, the ice machine should have an air gap to prevent backflow of liquid waste.
According to the USDA Food Code 2017 Section 5-202.13, Backflow Prevention, Air Gap, an air gap between the water supply inlet and the flood level rim of the plumbing fixture, equipment, or nonfood equipment, shall be at least twice the diameter of the water supply inlet and may not be less than 25 mm (1 inch) .
3. During a concurrent observation and interview with the DM 2, on 10/5/21, at 9:00 a.m., in the kitchen, the stainless steel can opener was observed with a black substance on the can opener blade. The DM 2 confirmed the can opener blade was not clean and stated, the can opener should be cleaned daily.
During a concurrent observation and interview with [NAME] 1, on 10/5/21, at 9:05 a.m., in the kitchen, the [NAME] 1 stated, he had not used the can opener that day.
Review of the facility's policy and procedure (P&P) titled, Can Opener, dated 5/1/2020, indicated, Can opener must be thoroughly cleaned each work shift and when necessary more frequently.

Based on interview, and record review, the facility's administrative staff failed to provide effective oversight and necessary resources to ensure resident care and services were met to attain or maintain the highest practicable physical, mental, and psychosocial well-being for five of nine sampled Residents (Resident 8, Resident 9, Resident 10, Resident 110, and Resident 118), when the facility did not implement elements from their initial certification survey plan of correction (POC) for F-tag 692. (Cross reference 692)
This failure had the potential to result in nutritional needs not being met for Residents 8, 9, 10, 110 and 118.
Findings:
During an interview on 2/16/22, at 11:36 a.m., with the Administrator (ADM), the ADM stated the facility had a quality assurance and performance improvement (QAPI- a systematic, comprehensive, and data-driven approach to maintaining and improving safety and quality in nursing homes while involving all nursing home caregivers in practical and creative problem solving) committee meeting on 12/30/21 to discuss the initial certification survey findings and plan of correction. The ADM was unable to state what processes were put into place for registered dietician (RD) assessments. The ADM stated she was not a clinician or an RD and stated, I have to trust that my staff is doing their jobs. The ADM stated department heads would turn in reports at the QAPI meeting. The ADM was unable to state how the information was utilized.
During an interview on 2/16/22, at 2:45 p.m., with the ADM, the ADM stated her oversight for facility processes was to hold stand-up meetings and quality assurance (QA) meetings. The ADM stated she evaluated the processes in the facility through reports turned in by department heads. The ADM was unable to state how the reports were used to determine if the performance improvement processes were effective. The ADM stated, I depend on other people to notify me if there is a failure. The ADM stated a lot of stuff is done by different departments out of my reach. We share some [staff] with the hospital like the supply person and dietary. The ADM stated she did not review the RD's report.
During an interview on 2/16/22, at 3:18 p.m., with the Director of Nursing (DON), the DON stated the facility implemented the plan of correction by hiring an RN supervisor. The DON stated the RN supervisor was responsible to review resident medical records for completion including assessments, care plans and documentation. The DON stated the RN supervisor did not reported any noncompliance to her. The DON avoided questions about what her responsibilities were with follow up on weights, nutritional assessments, follow through with doctor notification and care plans. The DON stated her duties were to review everything the clinical staff did including the RD.
During a concurrent interview and record review on 2/16/22 at 4:11 p.m., with the ADM, the facility document titled, Quality Assessment and Assurance Committee Minutes of Meeting, dated 12/30/21, was reviewed. The ADM stated the facility held QAPI meetings to discuss Things that stand out. The ADM stated the topic for the QAPI meeting on 12/30/21 were the deficiencies and the approved plan of correction from the initial certification survey (including F-692). The ADM reviewed the QAPI minutes and stated most of the minutes were left blank. The ADM stated, Not a lot of the QAPI is written down. Unless I had a scribe it is difficult for me to stand there and take the notes at the same time. The ADM stated it was difficult to determine if the new process was effective without documentation of the minutes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure nutritional assessments were performed by a qualified Registered Dietitian for one of 16 sampled residents (Resident 114) when:
The Dietary Manager failed to meet the qualifications and skill set to assess the facility's residents' nutritional status.
This failure posed the risk for residents' nutritional needs to not be met.
Findings:
The online dictionary defines review as a formal assessment or examination of something with the possibility of intention of instituting change if necessary this definition, therefore, implies a review as an assessment, a role designated for the RD.
Based on state regulations (California business and professions code 2586), the RD is the professional permitted to conduct medical nutrition therapy which includes assessment, determination of nutrition diagnosis and recommendation and implementation of nutrition care and intervention.
Review of the facility's policy and procedure revised September 2011, titled Nutritional Assessment showed, 1. The Dietitian, in conjunction with the nursing staff and healthcare practitioners, will conduct a nutritional assessment for each resident upon admission (within current initial assessment timeframes) and as indicated by a change in condition that places the resident at risk for impaired nutrition. 2. The nutritional assessment will be a systematic, multidisciplinary process that includes gathering and interpreting data and using the data to help define meaningful interventions for the resident at risk for or with impaired nutrition. 3. The nutritional assessment will be conducted by the multidisciplinary team and shall identify at least the following components: 4. Nursing, 5. Consultant Pharmacist, 6. Physicians and Practitioners, 7. Dietitian: a. An estimate of calorie, protein, nutrient, and fluid needs; b. whether the resident's current intake is adequate to meet his or her nutritional needs; and Special food formulations .
Review of the job description titled Dietary Coordinator signed and dated on 12/3/202 by the DM 1 showed, job duties included lifting requirements, working environment, exchange of ideas, workplace behaviors, safe working environment, and universal precautions. The job description did not include clinical job duties including conducting quarterly assessments or mini nutritional assessments as part of the job duties.
A review of the facility document titled, Weights and Vitals Summary (WVS), dated 10/8/21, indicated the following weights and comparisons for Resident 114:
5/7/21
121.2 lbs. (pounds., unit of measurement)
5/9/21
120 lbs.
5/15/21 122.1 lbs.
5/23/21 118.8 lbs. [-3.3. lbs. in one week]
5/29/21 117.8 lbs.
6/2/21
116 lbs.
6/6/21
117 lbs.
7/1/21
116.4 lbs.
8/6/21
111.6 lbs. (-7.5% change [comparison weight 5/15/21, 122.1 lbs., -8.6%, -10.5 lbs.]
9/3/21
111.6 lbs.
10/1/21 109.6 lbs. (-10% change [comparison weight 5/15/21, 122.1 lbs., -10.2%, -12.5lbs.]
On 10/7/21 at 11:56 a.m. a review of Resident 114's clinical record and concurrent interview was conducted with the RD 1. Upon review of the WVS dated 10/8/21, the RD 1 stated he would be concerned with the weight loss. Upon review of the quarterly assessment dated [DATE] completed by the DM 1, showed Resident 114's Section 1. Most Recent Weight: On 8/6/21 was 111.6 pounds (lbs.), Section 4. Diet order and percent intake: Regular diet with 56% intake, Section 12. Changes in the past quarter: No changes at this time. 13. Plan of action/Referrals: No significant weight changes. Monitor PO (oral intake) intake and weights as ordered. Encourage fluids and PO intake as tolerated. The RD 1 confirmed intake of 56% on a regular diet was not meeting Resident 114's nutritional needs. The RD 1 confirmed the quarterly nutritional assessment dated [DATE], completed by the DM 1 for Resident 114 was inaccurate and did not reflect the significant severe unplanned weight loss of 10.5 lbs., 8.6% in three months, from 5/15/21 through 8/6/21. The RD 1 further stated Resident 114's weight loss should have been referred to the RD. Upon review of the mini nutritional assessment (MNA) dated 8/9/21 completed by the DM 1, showed
Section i Instructions/Data a: Weight: 111.6 Date: 8/6/21, b. Height 60.0 Date: 5/7/21
Section ii Screening: A. Has food intake declined over the past 3 months due to loss of appetite, digestive problems, chewing or swallowing difficulties: 2. No decrease in food intake
B. Weight loss during the last 3 months: 3. No weight loss
C. Mobility: 1. Able to get out of bed/chair but does not go out.
D. Has suffered psychological stress or acute disease in the past 3 months: 2. No,
E Neuropsychological problems: 2. No psychological problems.
Section F1. Body Mass Index (BMI): 2. BMI 21 to 23
The RD 1 confirmed the mini nutritional assessment was inaccurate and did not reflect the significant severe unplanned weight loss of 10.5 lbs., 8.6% in three months, from 5/15/21 through 8/6/21. The RD 1 confirmed the practice of allowing a non-RD to complete nutritional assessments was not acceptable. The RD 1 further stated significant weight loss should be assessed by the RD.
On 10/7/21 at 3:07 p.m. a review of Resident 114's clinical record and concurrent interview was conducted with the Director of Nursing (DON). Upon review of the WVS for Resident 114, the DON stated, all newly admitted residents were weighed every week for four weeks and if stable, were weighed monthly. The DON confirmed Resident 114 experienced a significant severe unplanned weight loss of 10.5 lbs., 8.6% in three months, from 5/15/21 through 8/6/21. The quarterly nutritional assessment dated [DATE] completed by the DM 1, was reviewed with the DON. The DON confirmed the quarterly assessment was not accurate and did not reflect the significant severe unplanned weight loss of 10.5 lbs., 8.6% in three months, from 5/15/21 through 8/6/21. The DON stated, Resident 114's significant severe unplanned weight loss could result in further medical complications including anemia, electrolyte imbalance, dehydration, kidney failure, and further weight loss.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide outside services of Podiatry (DPM), Registered Dietician (RD), and Psychiatry for three (3) of sixteen (16) sampled residents and twenty-two (22) unsampled residents when:
1. A physician of podiatry was not contracted to provide services to the facility from 12/3/20 to 10/6/21. This failure resulted in podiatry services not being provided to Resident 117 and 109 as well as 22 other residents in need of podiatry physician evaluation. Resident 117 experienced pain, infection, and removal of the left great toenail and pain, and ingrown right great toenail for Resident 109 and placed the other twenty-two (22) residents at risk for pain, ingrown toenails, and infections.
2. A Registered Dietitian (RD) was not contracted to provide services to the facility from July 21, 2021 to August 19, 2021. This failure resulted in no RD assessments for Resident 114 and no effective interventions to address a significant severe weight loss of 10.5 lbs., 8.6% in three months, from 5/15/21 through 8/16/21 for Resident 114 to not be assessed or monitored by the RD.
3. A psychiatrist was not contracted to provide services to the facility from 12/3/20 to 10/14/21. This failure resulted in psychiatry services were not provided to Resident 114. This failure resulted in Resident 114 did not receive psychiatric assessments and placed Resident 114 at risk for decline in her mental health status.
These failures place the residents at risk for a decline in their health and safety.
Findings:
1. During a concurrent observation and interview, on 10/5/21 at 9:00 a.m., with Resident 109, Resident 109's toenails were extremely long, sharp, with brownish yellow discoloration on both feet. Resident 109's right great toenail was grown around the end of the toe in a circle and was pressing on his skin under the toe. Resident 109 stated he had not seen a podiatrist since admission to the facility 3/1/21.
During an interview on 10/5/21 at 9:11 a.m., with the Licensed Vocational Nurse (LVN) 2, LVN 2 stated she was familiar with Resident 109 and his toenails were long. LVN 2 stated she had told the Social Services Director Resident 109 needed to see a Podiatrist. LVN 2 stated the SSD was responsible for getting appointments for podiatry but had not made Resident 109 an appointment for podiatrist. LVN 2 stated the facility did not have a podiatrist.
During an interview, on 10/5/21 at 9:47 a.m., with the Social Services Director (SSD), the SSD stated LVN 2 had told her Resident 109 needed a podiatrist. The SSD stated the Regional Director of Operations (RDO) was working on getting a podiatry contract for the facility but had not done it. The SSD stated she did not know when the facility would get a podiatrist. The SSD stated Resident 109's toenails looked like talons. The SSD stated when the toenails were that thick and tough only a podiatrist could cut them. The SSD stated Resident 109 could experience sores from the nails pressing on his skin.
During a review of Resident 109's Face Sheet dated 3/1/21, the Face Sheet indicated Resident 109 was admitted to the facility on [DATE]. The Face Sheet indicated Resident 109 had diagnosis of Type 2 Diabetes Mellitus, Hemiparesis Following Intracerebral Hemorrhage Left Side (weakness following a stroke (bleeding in the brain), Congestive Heart Failure (weakness in the heart where fluid accumulates in the lungs), Hepatitis C (infection caused by virus that attacks the liver), Chronic Kidney Disease (impaired kidney function that worsens over time), and Difficulty Walking.
During a review of Resident 109's clinical records there was no documentation of assessment of his toenails in the nursing progress notes, physician's notes, or Activities of Daily Living (ADL) or any other records to indicate he was seen by a podiatrist.
During an interview, on 10/5/21 at 11:05 a.m. with the RDO, the RDO viewed a photograph of Resident 109's toenails taken 10/5/21. The RDO stated the facility did not have a contracted podiatrist. The RDO stated should have not waited to get a podiatrist.
During a concurrent observation and interview, on 10/6/21 at 9:03 a.m., with Resident 117, Resident 117's toenails were long, jagged, thick, and brownish yellow colored. Resident 117 pointed to his left great toenail and stated he was worried about, The bad one. The left great toenail had dark blackish coloration and looked infected and overgrown. Resident 117 stated he had not seen a podiatrist.
During a review of Resident 117's clinical records there was no documentation of assessment of his toenails in the nursing progress notes, physician's notes, or Activities of Daily Living (ADL) or any other records to indicate he was seen by a podiatrist.
During a review of Resident 117's Face Sheet dated 4/30/21, the Face Sheet indicated Resident 117 was admitted to the facility on [DATE]. The Face Sheet indicted Resident 117 had diagnosis of Idiopathic peripheral Autonomic Neuropathy (decreased feeling in the arms and legs), Osteomyelitis Multiple sites (infection in the bones), Type 2 Diabetes Mellitus, Ingrown Nail, Fracture of the Cervical, Thoracic and Lumbar Region (broken bones of the back), Chronic Obstructive Pulmonary Disease (constriction of the airway with difficult breathing), and Difficulty Walking.
During an interview, on 10/6/21 at 9:15 a.m., with the SSD, the SSD stated she was aware the facility needed a podiatrist. The SSD stated the RDO had found a podiatrist 10/5/21 and the podiatrist came to the facility 10/6/21 to treat 24 residents. When asked why the facility had not gotten a podiatrist before, the SSD stated, We couldn't find one to come out here.
During a concurrent observation and interview, on 10/6/21 at 12:45 p.m., with the Podiatrist (DPM), the DPM stated she was informed 10/5/21 the facility needed her services. The DPM viewed A photograph of Resident 109's toenails and stated the toenails appeared not to have been trimmed in about six (6) months. The DPM stated she had treated Resident 109 and he had an active toenail fungus that caused the toenails to thicken and become discolored and an ingrown right great toenail. The DPM stated she was very careful to not injure Resident 109 because he was diabetic. The DPM stated Resident 109 was high risk if the overgrown toenails grew into his skin and caused pressure sores. The DPM stated due to the condition of the toenails, Resident 109 should have seen a podiatrist and had his nails trimmed every two months. The DPM stated she had assessed and treated 22 other residents, but Residents 109 and 117 toenails were in the worst condition.
During a concurrent interview and record review, on 10/6/21 at 2:38 p.m., with the Podiatrist (DPM), the DPM stated she was made aware 10/5/21 the facility needed podiatry services. The DPM stated she had been coming to the area but no one from the facility had contacted her until yesterday. The DPM stated she had seen Resident 117, had removed the left great toenail and treated him for infection. The DPM stated the toenail had purulent (Yellow fluid from a wound-sign of infection) drainage under the toenail which caused redness and pain. The DPM stated the blackish color on the left great toenail was due to a previous injury where the nailbed bled and became blackened. The DPM stated she had ordered a betadine (disinfectant for skin) treatment daily to treat the left great toe. The DPM stated she did not know how long Resident 117's toe was infected. The DPM stated Resident 117 should have been treated by a podiatrist but was not.
During an interview, on 10/11/21 at 9:09 a.m., with the Administrator (ADM), the ADM stated the facility had been unable to get the Podiatrist to come to the facility. The ADM stated there was no Podiatry services at the facility from 12/2/20 to 10/6/21.
During an interview, on 10/13/21 at 8:37 a.m., with LVN 1, LVN 1 stated she had assessed Residents 109 and 117 about a month ago. LVN 1 stated she told SSD Residents 109 and 117 needed a podiatrist because she was unable to trim their toenails. LVN 1 stated the SSD told her she would follow up with a podiatrist but had not. LVN 1 stated long toenail could cause cuts, get caught on something or cause an infection. LVN 1 stated the long toenails would most likely have been painful. LVN 1 stated the condition of Resident 109 and 117's toenails should not have gotten that bad.
During a concurrent interview and record review, on 10/13/21 at 11:00 a.m., with the RDO, the contracts for outside services were reviewed. The RDO stated the facility had opened 12/3/20 and did not have a contracted podiatrist 12/3/20 to 10/6/21. The RDO stated it was his job to get physician contracted services for the facility. The RDO stated it was his expectation the facility would have podiatry care for the residents. The RDO stated the residents could have been harmed in many ways, especially since they were both diabetic. The RDO stated if he had been informed of the situation with Residents' 109 and 117's toenails, he would have acted but he was blindsided.
During a professional reference review of the Nursing Times article titled, Foot Assessment and Care for Older People dated 12/9/14, the article indicated, .Foot care can prevent mobility problems and social isolation; it is a crucial part of nursing care, particularly for older patients, who may be unable to care for their own feet .While foot problems can occur in all age groups, their prevalence increases with age. It is estimated that 80% of older people have foot problems . The prevalence of serious foot problems, such as peripheral arterial disease, does increase with age .Common foot problems in older people .Toenail disorders including hardened or ingrown nails .Toe deformities such as overlapping toes .Corns and calluses .Bunions .Fungal infections .If unattended such problems can lead to more serious issues .Those who are unable to perform this essential task for themselves need regular assessment and care to help prevent adverse effects from occurring .Dryness that is associated with reduced blood flow may cause the skin to split, resulting in painful fissures, while poor circulation may lead to a higher risk of infection .Toenails can thicken and become hard and brittle with age, which makes it difficult to cut them. Continuous pressure from inappropriate footwear can also cause more extreme nail deformity. Nails that become too long or thickened can damage the skin on adjacent toes .Ingrown toenails occur when a nail grows into the skin, and can cause pain, swelling, redness and infection .Fungal infection of skin, such as athlete's foot - which causes peeling, redness, itching, burning .Fungal nail infections occur when microscopic fungi enter the nail through a break; they result in thick, discolored and brittle nails .Foot assessment .When older people can no longer manage their own foot care, an initial assessment is required to identify what help they need .Podiatrists assess all new nursing home residents . After an individual has been assessed, care may be provided by Podiatrists' .
2. A review of an email provided by the facility from the Nutrition Consulting Company A, dated 7/23/21, at 4:55 p.m., indicated the last day of service for the Nutrition Consulting Company A was July 21, 2021.
A review of the contract with the Nutrition Consulting Company B indicated the contract began on August 19, 2021.
On 10/5/21 at 3:23 p.m. an interview was conducted with the Administrator (ADM). The ADM stated the RD 1 started consulting for the facility last week.
A review of Resident 114's Medical Record (MR), dated 10/8/21, indicated, Resident 114 was admitted on [DATE], with diagnoses that included Unspecified Dementia with Behavioral Disturbance (diminished memory with episodes of agitation or restlessness), Bipolar Disorder (feeling very sad or very excited), Circadian Rhythm Sleep Disorder (unable to sleep), Major Depressive Disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), Hyperlipidemia (elevated fat levels in the body), Muscle Weakness, Muscle Wasting and Atrophy (decreased muscle tissues), Psychotic Disorder with Delusions (a disorder characterized by a disconnection from reality) and Essential Hypertension (abnormally high blood pressure).
The most recent Minimum Data Set (MDS, a resident assessment tool) dated 8/18/21, indicated a BIMS (brief interview for mental status) score of 9 out of a possible 15, indicating Resident 114 was unable to complete the interview. Section C1000 of the MDS indicated, Resident 114's Cognitive Skills for Daily Decision Making was severely impaired.
Section K of the MDS indicated, Resident 114 had a weigh loss of 5% or more in the last month and was not on a physician- prescribed weight-loss regimen.
A review of the facility document titled, Weights and Vitals Summary (WVS), dated 10/8/21, indicated the following weights and comparisons for Resident 114:
5/7/21
121.2 lbs (pounds., unit of measurement)
5/9/21
120 lbs
5/15/21 122.1 lbs
5/23/21 118.8 lbs [-3.3. lbs in one week]
5/29/21 117.8 lbs
6/2/21
116 lbs
6/6/21
117 lbs
7/1/21
116.4 lbs
8/6/21
111.6 lbs (-7.5% change [comparison weight 5/15/21, 122.1 lbs., -8.6%, -10.5 lbs.]
9/3/21
111.6 lbs
A review of the facility document titled Order Summary Report (OSR), dated 10/8/21, indicated, on 5/07/21 a Regular diet, Regular texture, and Regular Liquids Consistency was ordered by the Physician for Resident 114.
During a concurrent interview and record review, on 10/07/21 at 12:44 p.m., with the Licensed Vocational Nurse (LVN) 1, Resident 114's Weights and Vitals Summary (WVS), dated [DATE] was reviewed. The LVN 1 stated, all newly admitted residents were weighed every week for four weeks and if stable, then weighted monthly. The LVN 1 stated, she would ask the Certified Nurse Assistant (CNA) to reweigh the resident for any weight loss. The LVN 1 stated, she would notify the doctor, the RD, the dietary department, and the responsible party (RP) for any significant or severe weight loss. The WVS indicated, on 5/15/21, Resident 114's weight was 122.1 lbs. On 8/6/21, Resident 114 weight was 111.6 lbs., a 10.5 lb., 8.6% weight loss in three months. The LVN 1 was unable to confirm nursing documentation in Resident 114's medical record which indicated the Physician, the RD, the dietary department, and the RP were notified when Resident 114 experienced an 8.6% significant severe unplanned weight loss in three months.
During a concurrent interview and record review, on 10/07/21 at 12:55 p.m., with LVN 1, Resident 114's Care Plan (CP), initiated on 5/11/21, was reviewed. The Focus Section of the CP indicated, the RD admission Assessment was completed on 5/13/21. The interventions/tasks section of the CP indicated, monitor/record/report to MD PRN signs and symptoms (s/s) of malnutrition: Emaciation (Cachexia), muscle wasting, significant weight loss: 3 lbs. in one week, >5% in one month, >7.5% in three months, >10% in six months. Provide, serve diet as ordered. Monitor intake and record every meal.
During a concurrent interview and record review, on 10/07/21 at 1:00 p.m., with the LVN 1, Resident 114's Progress Notes (PN) were reviewed. The LVN 1 was unable to confirm documentation the RD was notified of the significant severe unplanned weight loss of 10.5 lbs., 8.6% in three months, from 5/15/21 through 8/16/21.
During a concurrent interview and record review on 10/7/21 at 3:07 p.m., with the Director of Nursing (DON), the WVS and the PN for Resident 114 were reviewed. The DON stated, all newly admitted residents were weighed every week for four weeks and if stable, were weighed monthly. The DON confirmed Resident 114 experienced a significant severe unplanned weight loss of 10.5 lbs, 8.6% in three months, from 5/15/21 through 8/16/21. The DON stated, Resident 114's significant severe unplanned weight loss could result in anemia, electrolyte imbalance, dehydration, kidney failure, and further weight loss.
The DON was unable to confirm nursing documentation in Resident 114's medical record which indicated the Physician, the RD, the dietary department, and the RP were notified when Resident 114 experienced a significant severe unplanned weight loss of 10.5 lbs, 8.6% in three months, from 5/15/21 through 8/16/21.
During a concurrent interview and record review on 10/7/21 at 3:15 p.m., with the Director of Nursing (DON), Resident 114's Dietician Nutritional Assessment (DNA), dated 5/13/21 was reviewed. The DON stated, the DNA for Resident 114 was completed by the Registered Dietician (RD) 2. Section B of the DNA indicated, Resident 114's caloric needs were between 1,230 and 1,420 calories. Section D of the DNA indicated, Resident 114's fluid needs were between 1,230 and 1,420 ml (unit of measurement). Section F of the DNA indicated the goal for Resident 114 was Resident will not have a significant weight change. Section G of the DNA indicated interventions for Resident 114's was diet is liberalized. Continue POC (Plan of Care). RD to monitor weights and follow up as needed. The DON was unable to validate a DNA addressing the significant severe unplanned weight loss of 10.5 lbs., 8.6% in three months, from 5/15/21 through 8/16/21 was completed by the RD. The DON confirmed Resident 114 did not receive the appropriate follow-up assessment required by the RD according to the facility's policy.
During an interview on 10/7/21, at 5:24 p.m., with the LVN 3, the LVN 3 stated, Resident 114 fed herself, refused help, and frequently paced the hallway.
During a concurrent observation and interview inside Resident 114's room, on 10/7/21, at 5:30 p.m., with the CNA 3, the CNA 3 stated, Resident 114 fed herself, had good and bad days. The CNA 3 stated, she would offer a sandwich or something else if Resident 114 consumed 25% or less of her meals.
During an observation of the dinner meal service on 10/7/21, at 5:35 p.m., in Resident 114's room, Resident 114 was observed struggling to cut the chicken meat with a fork. Resident 114 used her hands to eat the chicken meat. Resident 114 consumed 90% of chicken, 75% of rice, 75% of vegetable and 100% of dessert. Resident 114 did not drink the milk. Resident 114 attempted to remove the water pitcher cover to drink water, however she was unable to remove the water pitcher cover. The CNA 3 assisted Resident 114 to remove the water pitcher cover and Resident 114 drank water directly from the pitcher.
During an interview on 10/7/21, at 5:51 p.m., with the LVN 1, the LVN 1 stated, she was not notified or aware of any change in intake or weight loss for Resident 114.
On 10/8/21 at 10:16 a.m., an interview was conducted with the RD 1. The RD 1 stated he started working at the facility two weeks ago. The RD 1 stated the facility had a loose system for monitoring weights. The RD 1 stated, there was not much communication between nursing and the RD or dietary department. The RD 1 stated, the CNAs were responsible for weighing residents weekly and monthly. The CNAs notified the licensed nurses of the weekly and monthly weights. The licensed nurses were responsible to enter the resident's weights in the electronic medical record. The RD 1 stated, the licensed nurses were responsible to notify the RD of any significant weight change. The RD 1 further stated the facility's goal was to manage resident's weight loss proactively.
On 10/8/21, at 11:55 a.m., an observation of Resident 114 was conducted. Resident 114 was observed walking slowly with a steady gait, wearing a loose blue upper garment, loose pants, and a pair of slippers. When Resident 114 was asked in her native language how she was doing, Resident 114 stated she was hungry.
During a concurrent observation and interview on 10/8/21, at 12:05 p.m., with the CNA 4 outside Resident 114's room, the CNA 4 stated, Resident 114's upper and lower garments were loose and looked too big for her.
During a concurrent observation and interview on 10/8/21, at 12:33 p.m., with the CNA 5 inside Resident 114's room, the CNA 5 stated, Resident 114 was on a regular diet and needed assistance with tray set-up. The CNA 5 set-up Resident 114's meal tray and Resident 114 begin eating her meal vigorously. CNA 5 stated, Resident 114 liked to be left alone during mealtimes.
Upon completion of Resident 114's lunch meal, on 10/8/21, at 12:51 p.m., Resident 114 consumed 100% of the fish, gelatin, and dinner roll. Resident 114 consumed 75% of the french fries and 25% of the cabbage salad. Resident 114 drank 100% (240 ml) of milk.
During a concurrent observation and interview on 10/8/21, at 1:19 p.m., with the CNA 6, the CNA 6 stated, Resident 114 consumed 100% of her lunch meal and drank 100% of her milk. CNA 6 validated Resident 114 didn't eat 100% of her cabbage salad.
During an interview on 10/8/21, at 3:48 p.m., with the RD 1, the RD 1 confirmed the significant severe unplanned weight loss of 8.6% within a three-month timeframe from 5/7/21 to 8/6/21 for Resident 114 were not addressed by the RD. The RD 1 further stated the weight loss for Resident 114 was not acceptable.
A review of the facility's policy and procedure (P&P) titled, Weight Assessment and Intervention, dated September 2020, the P&P indicated, Weight Assessment .1. The nursing staff will measure resident weights on admission, the next day, and weekly for four weeks thereafter. If no weight concerns are noted at this point, weights will be measure monthly thereafter .3. Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the Dietician in writing. Verbal notification must be confirmed in writing. 6. The threshold for significant unplanned and undesired weight loss will be based on the following criteria .b. 3 months - 7.5% weight loss is significant; greater than 7.5% is severe. C. 6 months - 10% weight loss is significant; greater than 10% is severe .Care Planning 1. Care planning for weight loss or impaired nutrition will be a multidisciplinary effort and will include the Physician, nursing staff, the Dietician, the Consultant Pharmacist, and the resident on resident's legal surrogate. 2. Individualized care plans shall address, to the extent possible: a. The identified cause of weight loss; b. Goals and benchmarks for improvement; and c. Time frames and parameters for monitoring and reassessment .
During a professional reference review of American Academy of Family Physicians Journal titled, Unintentional Weight Loss in Older Adults, dated 2014, the journal indicated, .Unintentional weight loss (i.e., more than a 5% reduction in body weight within six to 12 months) occurs in 15% to 20% of older adults and is associated with increased morbidity and mortality. In this population, unintentional weight loss can lead to functional decline in activities of daily living, increased in-hospital morbidity, increased risk of hip fracture in women, and increased overall mortality. Further, cachexia (loss of muscle mass with or without loss of fat) has been associated with negative effects such as increased infections, pressure ulcers, and failure to respond to medical treatments .
During a review of the facility's policy and procedure titled, CONSULTANTS dated 12/2009, the policy indicated, .Our facility uses outside resources to furnish specific services provided by the facility .To furnish specific services .On a consultant basis .Consultant services may be uses in the following areas .Dietary Services .Written, signed, dated agreements are maintained for each consultant .Each agreement contains .The responsibility of the consultant .The responsibility of the facility .The minimum number of hours to be provided by the consultant .Consultants provide the Administrator with written, dated, signed reports .Recommendations .Plans for implementation .Findings .Plans for continued assessments .
3. During a concurrent interview and record review, on 10/11/21 at 8:51 a.m., with the Director of Nurses (DON), the Physician's Orders (PO) for Resident 114 was reviewed. The DON stated Resident 114 had diagnosis of Bipolar Disorder (mental condition marked by periods of elation and depression), Major Depressive Disorder (chronic loss of interest/sadness), Psychotic Disorder (chemical imbalance in the brain marked by seeing or hearing things that are not there). The DON stated Resident 114 received two medications for mental illness, Olanzapine (medication for psychosis (hallucinations) 10 milligrams (mg-weight measurement) daily and Valproic acid (mood stabilizer) 125 mg twice a day since admission 5/7/21. The DON stated Resident 114 had behaviors of screaming, hitting herself, hallucinations and elopement. The DON confirmed there was no psychological evaluation for Resident 114. The DON stated the facility did not have a Psychiatrist to evaluate residents with mental illness. The DON stated the facility should have had psychiatric consultation for Resident 114 but did not.
During a concurrent interview and record review, on 10/11/21 at 11:32 a.m., with the Social Services Director (SSD), the SSD reviewed Resident 114's clinical records. The SSD confirmed Resident 114 was diagnosed with Psychosis and Bipolar Disorder and had not been evaluated by a psychiatrist. The SSD stated the facility did not have a psychiatrist since opening 12/3/20 to present. The SSD stated when she had asked corporate Regional Director of Operations (RDO) about psychiatric services, the RDO had told them the main hospital had taken too long to obtain the psychiatrist's credentials and psychiatric services were never started. The SSD stated corporate was responsible for contracting outside services for the facility but had not done it.
During an interview on 10/11/21 at 9:09 a.m., with the Administrator (ADM), the ADM stated the facility originally had contracts but were unable to get the Psychiatrist to come to the facility. The ADM stated there was no psychiatric services at the facility since opening 12/3/20. The ADM stated the facility should have had Resident 114 evaluated by a psychiatrist but did not.
During a review of Resident 114's Face Sheet dated 10/7/21, the Face Sheet indicated the admission date was 5/7/21. The Face Sheet indicated Resident 114 had diagnosis of Dementia (memory impairment), Bipolar Disorder (mental condition marked by periods of elation and depression), Major Depressive Disorder (chronic loss of interest/sadness), Psychotic Disorder (chemical imbalance in the brain marked by seeing or hearing things that are not there), Circadian Sleep Disorder (unable to sleep at regular times), Muscle Wasting (weakness and shrinking in the muscles), and Hypertension (higher than normal pressure in the blood vessels).
During a review of the facility's policy and procedure titled, Antipsychotic Medication Use dated 3/15, the policy indicated, .Antipsychotic medication may be considered for residents .Only after .Psychological, emotional psychiatric evaluations .
During a review of the facility's policy and procedure titled, CONSULTANTS dated 12/2009, the policy indicated, .Our facility uses outside resources to furnish specific services provided by the facility .To furnish specific services .On a consultant basis .Written, signed, dated agreements are maintained for each consultant .Each agreement contains .The responsibility of the consultant .The responsibility of the facility .The minimum number of hours to be provided by the consultant .Consultants provide the Administrator with written, dated, signed reports .Recommendations .Plans for implementation .Findings .Plans for continued assessments .The facility retains the professional and administrative responsibility for all services provided by consultants .Consultants serve on various committees of the facility .

Based on interview and record review, the facility failed to identify, develop and implement an effective QAPI (Quality Assurance and Performance Improvement- a systematic, comprehensive, and data-driven approach to maintaining and improving safety and quality in nursing homes while involving all nursing home caregivers in practical and creative problem solving) program. (Cross reference tag F-692)
This failure had the potential to affect the quality of care, quality of life, services and safety of the facility's residents.
Findings:
During a concurrent interview and record review on 2/16/22, at 11:36 a.m., with the administrator (ADM), the facility's document titled, Quality Assessment and Assurance Committee Minutes of Meeting, dated 12/30/21 was reviewed. The ADM stated the topic of the QAPI committee was the plan of correction (including tag F-692) from the initial certification survey. The ADM reviewed the QAPI minutes and stated the minutes were not complete. The ADM stated the discussion during the QAPI meeting had not been documented. The ADM reviewed the QAPI minutes and stated she was unable to determine what changes, recommendations and actions were suggested to meet the needs of resident's nutritional status. (Cross reference to F-692)
During a concurrent interview and record review on 2/16/22 at 4:11 p.m., with the ADM, the facility document titled, Quality Assessment and Assurance Committee Minutes of Meeting, dated 12/30/21 was reviewed. The ADM was unable to provide documentation of the QAPI committee recommendations and actions and stated the minutes indicated, see attached. The ADM stated Not a lot of the QAPI [meeting] is written down. Unless I had a scribe, it is difficult for me to stand there and take the notes at the same time.
During a review of the facility document titled, Quality Assessment and Assurance Committee Minutes of Meeting, dated 12/30/21, the QAPI minutes indicated, .Department/Topic . Dietary . Item/Status . presented by: Registered Dietician [name of RD] . a) Summary: [left blank] . b) Food PPE Cost: [left blank] . c) Test Tray Results: see attached . Threshold met/not met, Recommendation/Action . See Attached .
During a review of the facility's policy and procedure (P&P) titled, Quality Assurance and Performance Improvement (QAPI) Program, dated, February 2020, the P&P indicated, .This facility shall develop, implement, and maintain an ongoing, facility-wide data-driven QAPI Program that is focused on indicators of the outcomes of care and quality of life for our residents . Policy Interpretation and Implementation . objectives of the QAPI Program . 2. Provide a means to establish and implement performance improvement projects to correct identified negative or problematic indicators . 4. Establish systems through which to monitor and evaluate corrective actions . Authority . 3. The Administrator is responsible for assuring that this facility's QAPI Program complies with federal, stated and local regulatory agency requirements . 4. The QAPI Committee reports directly to the Administrator . Implementation 1. The QAPI Committee oversees implementation of our QAPI Plan, which is the written component describing the specifics of the QAPI program, how the facility will conduct its QAPI functions, and the activities of the QAPI Committee . 2. The QAPI plan describes the process for identifying and correcting quality deficiencies. Key components of this process include: a. Tracking and measuring performance; b. Establishing goals and thresholds for performance measurement; c. Identifying and prioritizing quality deficiencies; d. Systemically analyzing causes of systemic quality deficiencies; e. Developing and implementing corrective action or performance improvement activities; and f. Monitoring or evaluating the effectiveness of corrective action/performance improvement activities and revising as needed . 3. The committee meets monthly to review reports, evaluate data, and monitor QAPI-related activities and make adjustments .

Based on observation, interview and record review the facility failed to maintain a clean and safe environment for all residents in the facility when:
1.The ice machine located in the Skilled Nursing Facility (SNF) Supply Room was observed to have pink and green substance and white residue and to not be in a sanitary condition; the ice machine manufacturer's instructions for cleaning were not followed for two of two ice machines.
2.Two of two staff members (Licensed Vocational Nurse- LVN 4 and Certified Nursing Assistant- CNA 5) were observed to not use standard hand washing procedures while exiting a contact isolation room.
These failures had the potential to cause food born illnesses, transmission of communicable diseases and infections to all residents.
Findings:
1.During a concurrent observation and interview on 10/5/21, at 9:35 a.m., with the Maintenance Staff (MAINS) 1, the ice machine 1 located in the kitchen was inspected. The MAINS 1 stated he used a nickel safe generic cleaning solution to clean, sanitize and descale the ice machine.
During a concurrent observation and interview on 10/5/21, at 9:54 a.m., with the MAINS 1 in the SNF Supply Room, the interior of the ice machine 2 was inspected. When wiped with a paper towel, a pink slime and green substance were seen on the ice harvester (the area where the ice is produced) and the ice chute (the area where the ice enters the ice storage bin). A hard white residue was observed on the splash curtain (a plastic cover over the ice harvester). The MAINS 1 confirmed there should not be any type of residue on the inside surfaces of the ice machine. The MAINS 1 stated, the ice machine was cleaned and sanitized every six months or as needed. The MAINS 1 stated, the ice machine was cleaned last month [9/2021] by another maintenance staff. The MAINS 1 stated, the facility used generic chemicals to clean, sanitize and de-scale the ice machine.
During a concurrent interview and record review, on 10/5/21, at 10:05 a.m., with the MAINS 1, Food & Nutrition: Ice Machine - Cleaning and Sanitizing Log (LOG), undated was reviewed. The LOG indicated the most recent ice machine cleaning and sanitizing was completed on 9/10/21. The MAINS 1 stated, another maintenance staff cleaned the ice machines.
During an interview on 10/7/21, at 11:30 a.m., with the Registered Dietician (RD) 1 and the Dietary Manager (DM) 2, both the RD 1 and the DM 2 stated, the ice machines should be cleaned and serviced according to manufacturer's specifications and there should not be any type of residue on the inside surfaces of the ice machine.
Review of the ice machine's manufacturer service manual dated 2004, Section 3, Cleaning Procedure showed, Step 4, add the proper amount of the manufacturer's cleaning solution to the water trough.
Review of the ice machine manual titled, Installation and User's Manual for Self-Contained Cubes, dated May 2008, the manual indicated, Cleaning, Sanitation and Maintenance . 6. Pour 8 ounces [measurement for liquids] of Manufacturer's ice machine scale remover into the reservoir .11. Mix a cleaning solution of 1-ounce manufacturer's scale remover to 12 ounces of water .
During a review of the facility's policy and procedure (P&P) titled, Ice Machine, dated 5/2021, the P&P indicated, Policy: The ice machine will be cleaned and serviced as per manufacturer's specifications.
According to the USDA Food Code, dated 2017, Section 4-601.11, Equipment, Food-Contact Surfaces, Nonfood Contact Surfaces, and Utensils (A): Equipment food-contact surfaces and utensils shall be clean to sight and touch .
2.During an observation on 10/7/21, at 11:50 a.m., Licensed Vocational Nurse (LVN) 4 was seen exiting Resident 108's contact isolation (resident is roomed in a manner to prevent spread of infectious disease and requires staff to wear an isolation gown and gloves) room. LVN 4 exited the room and had Resident 108's insulin (medication to treat high blood sugar) in her hand, she opened the medication cart and put the insulin inside the cart and shut the cart without first performing hand hygiene. LVN 4 then reached over and used the hand sanitizer. Second observation on 10/7/21, at 12:10 p.m., LVN 4 removed Resident 108's foley catheter, she took off her gown and gloves, left the room and touched the mouse next to the computer with her hand without first performing hand hygiene. LVN 4 then reached over and used the hand sanitizer on the medication cart.
During an observation on 10/7/21, at 11:55 a.m., Certified Nursing Assistant (CNA) 5 was seen cleaning up Resident 108's urine, reach over with dirty gloves picked up Resident 108's call light and clipped it onto his pillow, then went back to cleaning up his urine. Second observation on 10/7/21, at 12:15 p.m., CNA 5 removed her gown and gloves and left Resident 108's room and touched the chair right outside his door and sat down without first performing hand hygiene. CNA 5 was not observed using hand sanitizer nor washing her hands after she left Resident 108's room.
During an interview on 10/7/21, at 12:25 p.m., with CNA 5, CNA 5 stated she did not clean her hands when she came out of the room. CNA 5 immediately got up and walked over to Resident 108's sink and washed her hands. CNA 5 stated it is important to wash hands or use the hand sanitizer to prevent the spread of germs.
During an interview on 10/7/21, at 5:25 p.m., with LVN 4, LVN 4 confirmed that she touched the medication cart to put away Resident 108's insulin before she used the hand sanitizer. LVN 4 stated, Before I touch anything, I should clean my hands, if not done this can spread germs and bacteria and cause infection.
During an interview on 10/8/21, at 9:05 a.m., with the Director of Nursing (DON), the DON stated it is important to wash hands or use hand sanitizer before and after putting on gloves and touching a resident also between going from a dirty area to a clean area one should change gloves wash or use hand sanitizer then put new gloves on. The DON stated washing hands and using hand sanitizer is the expectation and will help prevent the spread of infections.
During a review of the facility's P&P titled, Handwashing/Hand Hygiene, dated August 2015, indicated, . This facility considers hand hygiene the primary means to prevent the spread of infections . 1. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personal, residents, and visitors . 7. Use an alcohol-based hand rub . b. Before and after direct contact with residents; c. Before preparing or handling medications . E. Before and after handling an invasive devise (e.g., urinary catheters, IV [intravenous- in the vein] access sites) . h. Before moving from a contaminated body site to a clean body site during resident care; i. After contact with a resident's intact skin; j. After contact with blood or bodily fluids . m. After removing gloves; n. Before and after entering isolation precaution settings .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review, the facility failed to ensure three of five sampled residents (Resident 110, Resident 117, and Resident 128) were offered and/or received the Pneumococcal vaccinations. The facility also failed to ensure one of five sampled residents (Resident 122) was provided the education to make an informed decision to accept the Pneumococcal vaccine. These failures placed the three residents (Resident 110, 117, and 128) at risk of becoming infected with pneumonia and took away one resident (Resident 122) right to make an informed decision because the education was not provided on the pneumonia vaccine before it was given.
Findings:
During a concurrent interview and record review, on 10/11/21, at 4:11 p.m., with the Director of Nursing (DON), Resident 110's Minimum Data Set (MDS- a resident assessment tool used to identify resident care needs) dated 8/16/21, was reviewed. The DON confirmed the MDS for Resident 110 indicated the Pneumococcal vaccine was not offered. The DON stated Resident 110 should have been offered the Pneumococcal vaccine. The DON stated, It looks like the MDS LVN (Licensed Vocational Nurse- who is responsible for filling in the MDS for the residents) is just coding no and not offered instead she should have investigated further. Laziness.
During a concurrent interview and record review, on 10/11/21, at 4:11 p.m., with the DON, Resident 117's MDS, dated [DATE], was reviewed. The DON confirmed the MDS for Resident 117 indicated the Pneumococcal vaccine was not offered. The DON stated Resident 117 should have been offered the Pneumococcal vaccine, the wife (for Resident 117's) calls every month and has been more than happy for him to get his immunizations. I don't know why dates are not put in or why it wasn't offered.
During a concurrent interview and record review, on 10/11/21, at 4:11 p.m., with the Director of Nursing (DON), Resident 128's MDS, dated [DATE] was reviewed. The DON confirmed for Section O0300 for the Pneumovax vaccines Resident 128's MDS is marked 0. For No and reason 3. Not offered. The DON stated Resident 128 should have been offered the Pneumovax vaccine and the facility should have asked her resident representative (RP) if she was not able to make decisions for herself.
During a concurrent interview and record review, on 10/11/21, at 4:11 p.m., with the DON, Resident 122's MDS, dated [DATE], was reviewed. The DON confirmed the MDS for Resident 122 indicated that the Pneumococcal vaccine was not offered and gave no reason why. The DON confirmed that Resident 122 received the Pneumovax Dose 1 on 7/13/21 and that the MDS dated [DATE] was incorrect.
During a concurrent interview and record review, on 10/12/21, at 5:20 p.m., with the Director of Staff Development/Infection Preventionist (DSD/IP), Resident 122's Progress Notes on 7/13/21, at 5:47 p.m., indicated, resident received his PNA [pneumonia] vaccine today to right deltoid please monitor site x 72 hours consent signed order carried out resident was happy to get his vaccine for PNA. DSD/IP confirmed there were no progress notes to indicate education was given to Resident 122 on benefits and potential side effects.
During an interview on 10/13/21, at 10:23 a.m., with the DSD/IP, the DSD/IP stated we use the Pneumococcal and Influenza Vaccination Screening and Informed consent form Contraindications and Vaccination Status form, she stated this is part of the residents admission paperwork. The DSD/IP stated each resident should have this form and it should be uploaded to Point Click Care (PCC- the residents Electronic Healthcare records- EHR).
During a follow up interview on 10/13/21, at 3:35 p.m., with the DSD/IP, the DSD/IP stated the facility was not able to locate the Pneumococcal and Influenza Vaccination Screening and Informed consent form Contraindications and Vaccination Status form for Resident 110, Resident 117, Resident 122, and Resident 128. The DSD/IP stated all residents should be offered the pneumonia vaccine upon admission and the facility should be documenting if the resident has refused or agreed.
During a review of the facility's policy and procedure titled, Pneumococcal Vaccine, dated October 2019, indicated, . All residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections .1. Prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated will be offered the vaccine series within (30) days of admission to the facility unless medically contraindicated or the resident has already been vaccinated. 2. Assessment of pneumococcal vaccination status will be conducted within five (5) working days of the resident's admission if not conducted prior to admission. 3. Before receiving a pneumococcal vaccine, the resident or legal representative shall receive information and education regarding the benefit and potential side effects or the pneumococcal vaccine . Provision of such education shall be documented in the resident's medical record . 5. Residents/representatives have the right to refuse vaccination. If refused, appropriate entries will be documented in each resident's medical record indicating the date of the refusal of the pneumococcal vaccination .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the call light was within the reach of residents to call for staff assistance for three of 16 sampled residents (Resident 108, 110 & 128). These failures had the potential for Resident 108, 110, and 128 not being able to call for assistance if assistance was needed.
Findings:
During a review of Resident 110's Face Sheet (document that contains residents name, date of birth , room number, resident representative, diagnoses, insurance information and more) titled, admission RECORD, dated 10/5/21 at 3:45 p.m., indicated, . Resident 110 was admitted on [DATE] for Infection of amputation (surgically cutting off a limb) stump, left lower extremity . Osteomyelitis (inflammation of bone or bone marrow, usually due to infection) . Type 2 Diabetes Mellitus (A chronic condition that affects the way the body processes blood sugar.) . Cerebral infarction (stroke- a result of disrupted blood flow to the brain) . muscle weakness . Phantom limb syndrome (experience pain in the part of the limb that's no longer there) with pain .
During a review of Resident 110's Minimum Data Set (MDS- a standardized, primary screening and assessment tool of health status of a resident)- Version 3.0 Resident Assessment and Care Screening, dated 8/16/21, indicated, Resident 110 has the ability to express ideas and wants and had a Brief Interview of Mental Status (BIMS- test to see how well a resident is functioning cognitively (remembering, thinking, and reasoning- The total possible BIMS score ranges from 00. to 15. 13 - 15: cognitively intact. 08 - 12: moderately impaired. 00 - 07: severe impairment)) score of 14, indicating cognitively intact.
During a concurrent observation and interview on 10/5/21, at 9 a.m., with Resident 110, while in Resident 110's room, Resident 110's call light was seen on his dresser not within reach of the resident. Resident 110 stated he was not able to reach his call light. Resident 110 stated, Staff must have put it there after they cleaned me up this morning and forgot to put it back on my bed.
During a review of Resident 128's Face Sheet titled, admission RECORD, dated 10/5/21 at 3:45 p.m., indicated, .Resident 128 was admitted on [DATE] for Heart Failure (failure of the heart to function properly) . Chronic Obstructive Pulmonary Disease (COPD- chronic inflammatory lung disease that causes obstructed airflow from the lungs) . muscle weakness . Dementia (brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) with behavioral disturbance .
During a review of Resident 128's Minimum Data Set (MDS)- Version 3.0 Resident Assessment and Care Screening, dated 8/17/21, indicated, Resident 128 has the ability to express ideas and wants and had a Brief Interview of Mental Status (BIMS) score of 00, indicating severe impairment.
During an observation on 10/5/21, at 10:36 a.m., in Resident 128's room, Resident 128's call light was seen behind the privacy curtain, clipped to the base of the call light cord next to the wall on the roommates side of the room, out of reach for Resident 128.
During a review of Resident 108's Face Sheet titled, admission RECORD, dated 10/5/21 at 3:44 p.m., indicated, .Resident 108 was admitted on [DATE] for Apraxia (Difficulty with skilled movements even when a person has the ability and desire to do them) following unspecified Cerebrovascular Disease (a group of conditions that affect blood flow and the blood vessels in the brain) . Acute Kidney Failure (A condition in which the kidneys suddenly can't filter waste from the blood.) . Type 2 Diabetes with Diabetic Nephropathy (deterioration of kidney function) . Conversion disorder (a medical condition in which the brain and body's nerves are unable to send and receive signals properly) with seizures (a sudden, uncontrolled electrical disturbance in the brain) . Essential hypertension (high blood pressure that has no clearly identifiable cause) . Vitamin B 12 Deficiency Anemia (a condition in which your body does not have enough healthy red blood cells, due to a lack (deficiency) of vitamin B12) . Muscle weakness (generalized) . Benign Prostatic Hyperplasia ( condition in which an overgrowth of prostate tissue pushes against the urethra and the bladder, blocking the flow of urine) with lower urinary tract symptoms (hesitancy, poor and/or intermittent stream, straining, feeling of incomplete bladder emptying, dribbling, etc.) .
During a review of Resident 108's Minimum Data Set (MDS)- Version 3.0 Resident Assessment and Care Screening, dated 9/22/21, indicated, Resident 108 has the ability to express ideas and wants and had a Brief Interview of Mental Status (BIMS) score of 10, indicating moderately impaired.
During a concurrent observation and interview on 10/7/21, at 11:35 a.m., with Resident 108, while in Resident 108's room, Resident 108's call light was seen on the floor to the left of the resident's bed located next to resident's fall matt. Resident 108 stated, What call light, I have never used or seen a call light, I have to wait for them to come in the room so I can tell them what I need, I do yell at times but I don't like to.
During an interview on 10/11/21, at 2:52 p.m., with the Director of Nursing (DON), the DON stated that Resident 128 does not use her call light to get assistance she just wanders into the hallway. The DON stated even though Resident 128 doesn't use her call light it should still be attached to her bed for her to use. The DON stated all residents should have access to their call lights to call for assistance, this could be considered neglect if they cannot get the help they need. The DON stated not having their call light puts the resident's at risk for falls and not having their needs met.
During a review of the facility's policy and procedure titled, Answering the Call Light, dated October 2010, indicated, . The Purpose of this procedure is to respond to the resident's requests and needs . 5. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide foot care and make necessary podiatry appointments for two of sixteen sampled residents (Resident 109 and Resident 117) diagnosed with Type 2 Diabetes Mellitus (disease with impaired response to insulin, elevated blood sugar, decreased blood circulation in the feet), who had ingrown toenails (condition in which the side of the toenail grows into the flesh), and infected (disease caused by bacteria with swelling, redness and pus) toenails, and twenty-two unsampled residents that required podiatry assessments and treatments.
This failure resulted in the incision, drainage of pus, and removal of the left great toenail, pain, and infection for Resident 117, and pain, and ingrown right great toenail for Resident 109 and placed the other twenty-two (22) residents at risk for pain, ingrown nails, and infections which had the potential to affect the mobility of all residents.
Findings:
During a concurrent observation and interview, on 10/5/21 at 9:00 a.m., with Resident 109, Resident 109 was lying in his bed, on top of the blankets, with no shoes or socks on. Resident 109's toenails were long, sharp, with brownish yellow discoloration on both feet. Resident 109's right great toenail was grown around the end of the toe in a circle and was pressing on his skin under the toe. Resident 109's skin on his feet was dry with a large amount white peeling flakes. The Licensed Vocational Nurse (LVN) 2 was present at the door of the room and stated Resident 109 can be quiet and likes to be left alone. Resident 109 was alert, pleasant, articulate, and spoke Spanish. Resident 109 stated he had not seen a podiatrist and he trimmed his own nails. Resident 109 stated, He had lived on the streets before coming to the facility and took care of himself.
During a review of Resident 109's Face Sheet dated 3/1/21, the Face Sheet indicated Resident 109 was admitted to the facility on [DATE]. The Face Sheet indicated Resident 109 had diagnosis of Type 2 Diabetes Mellitus, Hemiparesis Following Intracerebral Hemorrhage Left Side (weakness following a stroke [bleeding in the brain]), Congestive Heart Failure (weakness in the heart where fluid accumulates in the lungs), Hepatitis C (infection caused by virus that affects the liver), Chronic Kidney Disease (impaired kidney function that worsens over time), and Difficulty Walking.
During an interview on 10/5/21 at 9:11 a.m., with the Licensed Vocational Nurse (LVN) 1, LVN 1 stated she was familiar with Resident 109 and was aware his toenails were very long. LVN 1 stated nurses were responsible for cutting the nails for residents with diabetes. LVN 1 stated she had told the Social Services Director Resident 109 needed to see a Podiatrist. LVN 1 stated the SSD was responsible for getting appointments for podiatry but had not made Resident 109 an appointment for podiatrist. LVN 1 stated the long toenails could cause skin breakdown (Sores from pressure) or problems with infection if they were not taken care of.
During an interview, on 10/5/21 at 9:38 a.m., with Certified Nursing Assistant 1 (CNA), CNA 1 stated Resident 109 had told her his toenails were too long. CNA 1 stated Resident 109's shoes probably rubbed the long toenails and hurt. CNA 1stated the LVN's were responsible for cutting the toenails of residents diagnosed with diabetes. CNA 1 stated the CNA's were allowed to file the residents toenails but she had not filed Resident 109's toenails because they were too long. CNA 1 stated Resident 109's long toenails could cause pain, infection, and that would be very bad for a diabetic resident.
During an interview, on 10/5/21 at 9:47 a.m., with the Social Services Director (SSD), the SSD stated LVN 1 had told her about Resident 109's toenails and the need for a podiatry appointment. The SSD stated she had not made Resident 109 an appointment but should have. The SSD stated the Regional Director of Operations (RDO) was working on getting a podiatry contract for the facility but had not done it. The SSD stated she did not know when the facility would get a podiatrist. The SSD stated they would have to get an appointment for podiatry in another town. The SSD stated she could have made an appointment for Resident 109 but had not. The SSD stated she was aware Resident 109 was diabetic. The SSD stated Resident 109's toenails were long and looked like talons. The SSD stated when the toenails were that thick and tough only a podiatrist could cut them. The SSD stated Resident 109 could experience pressure sores from the nails pressing on his skin.
During an interview, on 10/5/21 at 11:05 a.m. with the RDO, the RDO viewed a photograph of Resident 109's toenails. The RDO stated the facility should have made Resident 109 a podiatry appointment and not waited for the facility to get a contract.
During a concurrent observation and interview, on 10/6/21 at 9:03 a.m., with Resident 117, Resident 117 was lying in his bed without socks or shoes. Resident 117's toenails were long, jagged, thick, and brownish yellow colored. Resident 117's fingernails were long and had yellow substance under the nails. Resident 117's skin on his feet had patches of thick, yellow colored, peeling skin. The tissue around the nails was dry and had peeling skin. Resident 117 pointed to his left great toenail and stated he was worried about, The bad one. The left great toenail had dark blackish coloration and was jagged and overgrown. Resident 117 stated he had not seen a podiatrist.
During a review of Resident 117's Face Sheet dated 4/30/21, the Face Sheet indicated Resident 117 was admitted to the facility on [DATE]. The Face Sheet indicated Resident 117 had diagnosis of Idiopathic peripheral Autonomic Neuropathy (decreased feeling in the arms and legs), Osteomyelitis Multiple sites (infection in the bones), Type 2 Diabetes Mellitus, Ingrown Nail, Fracture of the Cervical, Thoracic and Lumbar Region (broken bones of the back), Chronic Obstructive Pulmonary Disease (constriction of the airway with difficult breathing), and Difficulty Walking.
During an interview, on 10/6/21 at 9:15 a.m., with the SSD, the SSD stated the facility had contracted a podiatrist to come to the facility on [DATE]. The SSD stated the podiatrist had been at the facility since 6:00 a.m. The SSD stated the podiatrist planned to see about 24 residents. When asked why the facility had not gotten a podiatrist before, the SSD stated, We couldn't find one to come out here.
During a concurrent observation and interview, on 10/6/21 at 12:45 p.m., with the Podiatrist (DPM), the DPM stated she was informed 10/5/21 the facility needed her services. The DPM viewed a photograph of Resident 109's toenails and stated the toenails appeared not to have been trimmed in about six (6) months. The DPM stated she had treated Resident 109, and he had an active toenail fungus that caused the toenails to thicken and become discolored. The DPM stated she was very careful to not injure Resident 109 because he was diabetic. The DPM stated Resident 109 was high risk if the overgrown toenails grew into his skin and caused pressure sores. The DPM stated due to the condition of his toenails, Resident 109 should have seen a podiatrist and had his nails trimmed every two months by a podiatrist. The DPM stated she ordered A&D ointment (petroleum-based skin moisturizer) every other day to relieve the dry skin on his feet. The DPM stated she had assessed and treated 22 other residents at the facility, but Residents 109 and 117 toenails were in the worst condition.
During a concurrent interview and record review, on 10/6/21 at 2:38 p.m., with the DPM, the DPM stated she had seen Resident 117. The DPM's notes for Resident 117 indicated she had removed the left great toenail. The DPM stated she had to remove Resident 117's left great toenail due to infection. The DPM stated the toenail had purulent (yellow fluid from a wound-which indicated a sign of infection) drainage under the toenail which caused redness and pain. The DPM stated the blackish color on the left great toenail was due to a previous injury where the nailbed bled and became blackened. The DPM stated she ordered antibiotics for Resident 117. The DPM stated she ordered a betadine (disinfectant for skin) treatment daily to the left great toe. The DPM stated she did not know how long Resident 117's toe was infected. The DPM stated Resident 117 should have been treated by a podiatrist every two months but was not.
During a review of the DPM notes, dated 10/6/21, the notes indicated .Skin .Dry .Nails .Hypertrophic (overgrown) .Yellow .Thick .Subungual Debris (thickened discolored nails) .L [Left] Hallux (big toe) Paronychia (infection of tissue under nail) TNA (total nail avulsion (removal) Mod [moderate] Drainage & Pain .Absent right third toe nail .Comp History +Physical Exam High Complexity .Nail Debridement (removal of diseased nail bed tissue .Trimming of dystrophic (misshaped, thickened) nails .Rx (prescription) (L) Hallux Beta (betadine (antiseptic solution for injuries) x 21 days, Paronychia [with] infection ingrown .Rx Keflex (antibiotic used to treat infection) 500 mg 1 [by mouth] [twice a day] x7 days .
During a concurrent interview and record review, on 10/12/21 at 4:01 p.m., with the Director of Nursing (DON), the DON was not able to find any documentation of nail care provided for Residents 109 or 117. The DON stated the LVN's were responsible for diabetic residents' foot care. The DON stated she did not monitor the nail care documentation of the LVN's. The DON stated she was responsible for supervision of the LVN's. The DON stated medical records monitored and told her when there were omissions. The DON stated she had not assessed Resident 109 or 117's feet because the LVN's had not told her there was a problem. The DON stated the LVN's had not told her about these two resident's nail care needs and they should have.
During a concurrent interview and record review, on 10/12/21 at 4:10 p.m., with the Director of Staff Development (DSD), the nail care records for Residents' 109 and 117 were reviewed. The DSD stated she was not sure how to run a report for nail care documentation. The DSD stated she did not monitor when the LVN's performed nail care for diabetic residents. The DSD stated the LVN's did weekly assessment and when they had concerns, they should report it to the DON. The DSD stated the condition of Residents' 109 and 117's toenails were concerning and should have been reported. The DSD stated she had not been informed of the condition of the residents' toenails. The DSD stated she expected the LVN's would have informed the doctor so he could have looked at it. The DSD stated Residents 109 and 117 could have experienced pain, infection, loss of the nail, inflammation and drainage. The DSD stated the DON was responsible for the nursing department. The DSD stated the last documentation for nail care for Residents 109 and 117 was 5/21. The DSD stated there was no nail care documentation by the LVN's for 6/21, 7/21, 8/21, 9/21, or 10/21.
During a concurrent interview and record review, on 10/13/21, at 8:11 a.m., the Interim Medical Records (IMR) reviewed the Activities of Daily Living (ADL) and the weekly nursing assessments done by the LVN's for Residents 109 and 117. The IMR stated the last nail care documented on the ADL's for Resident 109 was 5/1/21 and for Resident 117 was 5/1/21. The LVN documentation for diabetic nail care dated 6/21, 7/21, 8/21, 9/21 and 10/21 for Residents 109 and 117 indicated there was no nail care. The IMR stated LVN's should have done more frequent nail care and referred them to a podiatrist. The IMR stated the DON was responsible for monitoring the LVN's work. The IMR stated the LVN's should have told the DON about the residents' nail care and incorporated her help.
During a concurrent interview and record review, on 10/13/21, at 8:37 a.m., with LVN 2, the nursing assessments 5/21-10/21 were reviewed. LVN 2 stated she had assessed Residents 109 and 117 about a month ago. LVN 2 stated she told SSD Residents 109 and 117 needed a podiatrist because she was unable to trim their toenails. LVN 2 stated the SSD told her she would follow up with a podiatrist but had not. LVN 2 stated she did not know if the facility had gotten podiatrist. LVN 2 stated long toenail could cause cuts, get caught on something or cause an infection. LVN 2 stated the long toenails would most likely have been painful. LVN 2 stated she believed the DON did assessments on the residents but didn't know how often. LVN 2 stated the condition of Resident 109 and 117's toenails should not have gotten that bad.
During an interview on 10/13/21, at 11:00 a.m., with the RDO, the RDO stated the facility had opened 12/3/21. The RDO stated it was difficult to get physician contracted services due to the distance. The RDO stated the facility had contracts when they opened but the podiatrist had not come to the facility since opening. The RDO stated it was his job to get physician contracted services for the facility. The RDO stated it was his expectation the facility would have sent Residents 109 and 117 to the podiatrist for treatment. The RDO stated the residents could have been harmed in many ways, especially since they were both diabetic. The RDO stated if he had been informed of the situation with Residents' 109 and 117's toenails, he would have acted but he was blindsided.
During a review of the facility's undated document titled, Licensed Practical/Vocational Nurse-SNF Job Description, the document indicated, .This job description is a record of the essential functions of the listed job .This position involves direct patient care .The Licensed Vocational Nurse provides .Medical treatment and personal care services to .Persons in a skilled nursing facility setting by performing the following duties .Be dedicated to the provision of quality care, and use sound judgement in decision making .Responsibilities to the Patient .Observes patients and reports .To medical personnel in charge .Communicates the plan of nursing care for each patient through reports .Provides a level of competency to treat patients .Involves them with care planning by meeting any needs identified during assessment .Communication .Timely follow up .
During a review of the facility's policy and procedure titled, Care Area Assessments dated 5/2011, the policy indicated, .Care Area Assessments (CAAs) will be used to .Develop individualized care plans .CAAs are the link between assessment and care planning .Identify areas of concern .Review by .doing an in-depth, resident specific assessment of the triggered condition .History .Physical assessment .The IDT will employ tools and resources .Factors that should be considered in developing the care plan .Any need for further evaluation by the physician or other healthcare provider .
During a review of the facility's policy and procedure titled, Care of Fingernails/Toenails dated 2010, indicated, The purpose of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections .Nail care includes daily cleaning and regular trimming .Trimmed and smooth nails prevent the residents from accidentally scratching and injuring his or her skin .Watch for and report changes .Stop and report to the nurse supervisor if there is evidence of ingrown nails, infections, pain, or if the nails are too hard or too thick to cut .DOCUMENTATION .The following information should be recorded in the resident's medical record .The condition of the resident's nails .Bluish or dark color of nail beds .ingrown nails .Pain .Any difficulties in cutting the resident's nails .Interventions taken .
During a review of the Nursing Times article titled, Foot Assessment and Care for Older People dated 12/9/14, the article indicated, .Foot care can prevent mobility problems and social isolation; it is a crucial part of nursing care, particularly for older patients, who may be unable to care for their own feet .While foot problems can occur in all age groups, their prevalence increases with age. It is estimated that 80% of older people have foot problems . The prevalence of serious foot problems, such as peripheral arterial disease, does increase with age .Common foot problems in older people .Toenail disorders including hardened or ingrown nails .Toe deformities such as overlapping toes .Corns and calluses .Bunions .Fungal infections .If unattended such problems can lead to more serious issues .Those who are unable to perform this essential task for themselves need regular assessment and care to help prevent adverse effects from occurring .Dryness that is associated with reduced blood flow may cause the skin to split, resulting in painful fissures, while poor circulation may lead to a higher risk of infection .Toenails can thicken and become hard and brittle with age, which makes it difficult to cut them. Continuous pressure from inappropriate footwear can also cause more extreme nail deformity. Nails that become too long or thickened can damage the skin on adjacent toes .Ingrown toenails occur when a nail grows into the skin, and can cause pain, swelling, redness and infection .Fungal infection of skin, such as athlete's foot - which causes peeling, redness, itching, burning .Fungal nail infections occur when microscopic fungi enter the nail through a break; they result in thick, discolored and brittle nails .Foot assessment .When older people can no longer manage their own foot care, an initial assessment is required to identify what help they need .Podiatrists assess all new nursing home residents . After an individual has been assessed, care may be provided by Podiatrists . Referrals should be made to podiatrists, GPs, or pharmacists (for medication review) if patients have .Medical complications that put feet at risk, such as diabetes with peripheral vascular disease, significant peripheral arterial disease .Painful foot lesions, including severe deformities and toenails that are excessively thickened and cause pain, prevent mobility or are a risk to surrounding skin .Loss of sensation .Patients with diabetes who have an increased risk must have an expert assessment carried out by health professionals with specialist experience in the management of the foot in diabetes. Registered nurses should know who to refer and should ensure a timely referral is made and response given .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for three (Residents 114, 112, 108) of 16 sampled residents when:
1. Resident 114 experienced an 8.7% weight loss within the three-month period and a 12.2% weight loss within the five-month period and the care plan did not address this situation.
This failure resulted in Resident 114 to have an on-going severe significant unplanned weight loss for five months since admission to the facility.
2. Resident 112 did not have a care plan to address the 15.6% weight loss within the three-month period and the 13.2% weight loss within the four-month period.
This failure resulted in Resident 112 to have an on-going severe significant unplanned weight loss for four months since admission to the facility.
3. Resident 108's care plan for oral/dental health problems contained interventions that were not followed.
This failure resulted in Resident 108's oral/dental health not being followed and had the potential for Resident 108 to have oral/dental infections.
These findings placed Residents 114, 112 and 108 at risk for a decline in their health and safety and unable to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.
Findings:
1. During a review of Resident 114's Medical Record (MR), dated 10/8/21, the medical record indicated, Resident 114 was admitted on [DATE], with diagnoses that included Unspecified Dementia with Behavioral Disturbance (diminished memory with episodes of agitation or restlessness), Bipolar Disorder (feeling very sad or very excited), Circadian Rhythm Sleep Disorder (unable to sleep), Major Depressive Disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), Hyperlipidemia (elevated fat levels in the body), Muscle Weakness, Muscle Wasting and Atrophy (decreased muscle tissues), Psychotic Disorder with Delusions (a disorder characterized by a disconnection from reality) , and Essential Hypertension (abnormally high blood pressure).
The most recent Minimum Data Set (MDS, a resident assessment tool used to identify resident care needs) dated 8/18/21, indicated a BIMS (brief interview for mental status) score of 99 out of a possible 15, indicating Resident 114 was unable to complete the interview. Section C1000 of the MDS indicated, Resident 114's Cognitive (ability to think and reason) Skills for Daily Decision Making was severely impaired. Section K of the MDS indicated, Resident 114 had a weigh loss of 5% or more in the last month and not on physician-prescribed weight-loss regimen.
During a review of the facility's document titled, Weights and Vitals Summary (WVS), dated 10/8/21, the form indicated the following weights and comparisons for Resident 114:
5/7/21
121.2 lbs. (pounds., unit of measurement)
5/9/21
120 lbs.
5/15/21
122.1 lbs.
5/23/21
118.8 lbs. [-3.3. lbs. in one week]
5/29/21
117.8 lbs.
6/2/21
116 lbs.
6/6/21
117 lbs.
7/1/21
116.4 lbs.
8/6/21
111.6 lbs. (-7.5% change [comparison weight 5/15/21, 122.1 lbs., -8.6%, -10.5 lbs.])
9/3/21
111.6 lbs.
10/1/21
109.6 lbs. (-10% change [comparison weight 5/15/21, 122.1 lbs., -10.2%, -12.5 lbs.])
During a review of Resident 114's Order Summary Report (OSR), dated 10/8/21, indicated, Resident 114 diet was ordered on 5/07/21 by the physician, indicating Regular diet, Regular texture, and Regular Liquids Consistency.
During a concurrent interview and record review, on 10/07/21, at 12:55 p.m., with Licensed Vocational Nurse (LVN) 1, Resident 114's Care Plan (CP), initiated on 5/11/21, was reviewed. The Focus Section of the CP indicated, the RD (Registered Dietician) admission Assessment was completed on 5/13/21. The interventions/tasks section of the CP indicated, monitor/record/report to MD PRN signs and symptoms (s/s) of malnutrition: Emaciation (Cachexia), muscle wasting, significant weight loss: 3 lbs. in one week, >5% in one month, >7.5% in three months, >10% in six months. Provide, serve diet as ordered. Monitor intake and record every meal.
During a concurrent interview and record review, on 10/07/21, at 12:55 p.m., with LVN 1, Resident 114's Care Plan (CP), initiated on 5/11/21, was reviewed. The Interventions/Tasks of the CP indicated, RD to evaluate and make diet change recommendations PRN. LVN 1 was unable to confirm documentation the RD evaluated or make a diet change recommendation for Resident 114 after establishing the initial care plan on 5/11/21. LVN 1 stated Resident 114's care plan for RD to evaluate and make diet change recommendations was not followed.
During a concurrent interview and record review, on 10/07/21, at 3:07 p.m., with the DON, Resident 114's Progress Notes (PN), were reviewed. The DON was unable to confirm documentation the physician was notified for s/s of malnutrition: Emaciation (Cachexia), muscle wasting, significant weight loss: 3 lbs. in one week, >5% in one month, >7.5% in three months, >10% in six months. The DON stated Resident 114's care plan to notify the physician for significant weight loss was not followed. The DON stated Resident 114's significant severe unplanned weight loss could result in anemia, electrolyte imbalance, dehydration, kidney failure, and further weight loss.
During a concurrent interview and record review, on 10/07/21, at 12:55 p.m., with the DON, Resident 114's Care Plan (CP), initiated on 5/11/21, was reviewed. The Interventions/Tasks of the CP indicated, RD to evaluate and make diet change recommendations PRN. The DON was unable to confirm documentation the RD evaluated or make a diet change recommendation for Resident 114 after establishing the initial care plan on 5/11/21. The DON stated Resident 114's care plan for RD to evaluate and make diet change recommendations was not followed.
During an interview on 10/8/21, at 3:48 p.m., with RD 1, RD 1 confirmed the significant severe unplanned weight loss of 8.6% within a three-month timeframe from 5/7/21 to 8/6/21 and the significant severe unplanned weight loss of 10.2 % within a five-month timeframe from 5/7/21 to 10/1/21 for Resident 114 were not addressed by the RD. RD 1 further stated the weight loss for Resident 114 was not acceptable.
During a review of the facility's policy and procedure, titled, Care Plans - Comprehensive dated 9/2010, indicated, An individualized comprehensive care plan that is measurable objective and timetables to meet resident's medical, nursing, mental and psychological needs is developed for each resident .1. Our facility's Care Planning .care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. 2. The comprehensive care plan is based on a thorough assessment that is not limited to the MDS. 3. Each resident's comprehensive care plan is designed to: a. Incorporate identified problem areas; b. Incorporate risk factors associated with identified problems .f. Identify professional services that are responsible for each element of care .9. The Care Planning/Interdisciplinary Team (IDT) is responsible for the review and updating of the care plans: a. When there has been a significant change in resident's condition .d. At least quarterly.
During a review of the facility's policy and procedure (P&P) titled, Weight Assessment and Intervention, dated September 2020, the P&P indicated, .Weight Assessment .1. The nursing staff will measure resident weights on admission, the next day, and weekly for four weeks thereafter. If no weight concerns are noted at this point, weights will be measure monthly thereafter .3. Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the Dietician in writing. Verbal notification must be confirmed in writing. 6. The threshold for significant unplanned and undesired weight loss will be based on the following criteria .b. 3 months - 7.5% weight loss is significant; greater than 7.5% is severe. C. 6 months - 10% weight loss is significant; greater than 10% is severe .Care Planning 1. Care planning for weight loss or impaired nutrition will be a multidisciplinary effort and will include the Physician, nursing staff, the Dietician, the Consultant Pharmacist, and the resident or resident's legal surrogate. 2. Individualized care plans shall address, to the extent possible: a. The identified cause of weight loss; b. Goals and benchmarks for improvement; and c. Time frames and parameters for monitoring and reassessment .
During a professional reference review of American Academy of Family Physicians Journal titled, Unintentional Weight Loss in Older Adults, dated 2014, indicated, .Unintentional weight loss (i.e., more than a 5% reduction in body weight within six to 12 months) occurs in 15% to 20% of older adults and is associated with increased morbidity and mortality. In this population, unintentional weight loss can lead to functional decline in activities of daily living, increased in-hospital morbidity, increased risk of hip fracture in women, and increased overall mortality. Further, cachexia (loss of muscle mass with or without loss of fat) has been associated with negative effects such as increased infections, pressure ulcers, and failure to respond to medical treatments .
2. During a review of Resident 112's Medical Record (MR), dated 10/5/21, indicated, Resident 112 was admitted on [DATE], with diagnoses that included Unspecified Dementia with Behavioral Disturbance (diminished memory with episodes of agitation or restlessness), Anxiety Disorder, unspecified Anxiety Disorder (a mental health illness characterized by a sudden feeling of panic and fear, restlessness, and uneasiness), Unspecified Urinary Incontinence, Wedge Compression Fracture of First Lumbar Vertebra (a fracture often caused by trauma such as sustaining a fall, occurs in front of the vertebra and resulting on a wedge shape), Vitamin D deficiency (lack of) and Muscle Wasting and Atrophy (decreased muscle tissues).
The most recent Minimum Data Set (MDS) dated [DATE], Section C1000 indicated, Resident 112's Cognitive Skills for Daily Decision Making was severely impaired. Section K of the MDS indicated, Resident 112 has a swallowing disorder and complaints of difficulty or pain with swallowing.
During a review of the facility's document titled, Weights and Vitals Summary (WVS), dated 10/8/21, the form indicated the following weights and comparisons for Resident 112:
5/25/21
107.4 lbs. (pounds., unit of measurement)
6/3/21
92.5 lbs.
6/20/21
92.0 lbs. (-10.0% change, [comparison weight 5/25/21, 107.4 lbs., -14.3%, -10.6lbs.])
7/1/21
95.3 lbs. (-10.0% change, [comparison weight 5/25/21, 107.4 lbs., -11.3%, -12.1lbs.])
8/1/21
96.4 lbs. (-10.0% change, [comparison weight 5/25/21, 107.4 lbs., -10.2%, -11 lbs.])
8/29/21
90.9 lbs. (-10.0% change, [comparison weight 5/25/21, 107.4 lbs., -15.6%, -16.8 lbs.])
9/3/21
90.6 lbs. (-10.0% change, [comparison weight 5/25/21, 107.4 lbs., -15.6%, -16.8 lbs.])
10/1/21
93.2 lbs. (-10.0% change, [comparison weight 5/25/21, 107.4 lbs., -13.2%, -14.2 lbs.])
During a concurrent interview and record review, on 10/08/21 at 12:44 p.m., with the Director of Staff Development (DSD), Resident 112's WVS and Care Plan (CP), dated 10/8/2021 were reviewed. DSD stated, all newly admitted residents were weighed every week for four weeks and if stable, then weights were done monthly. The WVS indicated, on 7/1/21, Resident 112's weight was 95.3 lbs., a 12.1 lbs., 11.3% weight loss in one month since admission to the facility. On 8/29/21, Resident 112's weight was 90.9 lbs., a 16.8 lbs., 15.6% weight loss in three months. Resident 112's admission weight on 5/25/21 was 107.4 lbs. The DSD reviewed resident 112's care plans and stated there was no care plan developed to address the weight loss on 6/20/21, 7/21/21, 8/1/21, 8/29/21, 9/3/21, and 10/1/21. The DSD stated, Resident 112 should have a weight loss care plan and nutrition care plan as soon as the weight loss was identified. The DSD stated it was the responsibility of the licensed nurse or DON to initiate the care plan.
During a review of the facility's policy and procedure, titled, Care Plans - Comprehensive dated September 2010, indicated, .An individualized comprehensive care plan that is measurable objective and timetables to meet resident's medical, nursing, mental and psychological needs is developed for each resident .1. Our facility's Care Planning .care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. 2. The comprehensive care plan is based on a thorough assessment that is not limited to the MDS. 3. Each resident's comprehensive care plan is designed to: a. Incorporate identified problem areas; b. Incorporate risk factors associated with identified problems .f. Identify professional services that are responsible for each element of care .9. The Care Planning/Interdisciplinary Team (IDT) is responsible for the review and updating of the care plans: a. When there has been a significant change in resident's condition .d. At least quarterly .
During a review of the facility's policy and procedure (P&P) titled, Weight Assessment and Intervention, dated September 2020, the P&P indicated, Weight Assessment .1. The nursing staff will measure resident weights on admission, the next day, and weekly for four weeks thereafter. If no weight concerns are noted at this point, weights will be measure monthly thereafter .3. Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the Dietician in writing. Verbal notification must be confirmed in writing. 6. The threshold for significant unplanned and undesired weight loss will be based on the following criteria .b. 3 months - 7.5% weight loss is significant; greater than 7.5% is severe. C. 6 months - 10% weight loss is significant; greater than 10% is severe .Care Planning 1. Care planning for weight loss or impaired nutrition will be a multidisciplinary effort and will include the Physician, nursing staff, the Dietician, the Consultant Pharmacist, and the resident or resident's legal surrogate. 2. Individualized care plans shall address, to the extent possible: a. The identified cause of weight loss; b. Goals and benchmarks for improvement; and c. Time frames and parameters for monitoring and reassessment .
During a professional reference review of American Academy of Family Physicians Journal titled, Unintentional Weight Loss in Older Adults, dated 2014, the journal indicated,
.Unintentional weight loss (i.e., more than a 5% reduction in body weight within six to 12 months) occurs in 15% to 20% of older adults and is associated with increased morbidity and mortality. In this population, unintentional weight loss can lead to functional decline in activities of daily living, increased in-hospital morbidity, increased risk of hip fracture in women, and increased overall mortality. Further, cachexia (loss of muscle mass with or without loss of fat) has been associated with negative effects such as increased infections, pressure ulcers, and failure to respond to medical treatments .
3. During a review of Resident 108's Face Sheet (document that contains residents name, date of birth , room number, resident representative, diagnoses, insurance information and more) titled, admission and Records, dated 10/5/21 at 3:44 p.m., indicated, .Resident 108 was admitted on [DATE] for Apraxia (Difficulty with skilled movements even when a person has the ability and desire to do them) following unspecified Cerebrovascular Disease (a group of conditions that affect blood flow and the blood vessels in the brain) . Acute Kidney Failure (A condition in which the kidneys suddenly can't filter waste from the blood.) . Type 2 Diabetes (A chronic condition that affects the way the body processes blood sugar.) with Diabetic Nephropathy (deterioration of kidney function) . Conversion disorder (a medical condition in which the brain and body's nerves are unable to send and receive signals properly) with seizures (a sudden, uncontrolled electrical disturbance in the brain) . Essential hypertension (high blood pressure that has no clearly identifiable cause) . Vitamin B 12 Deficiency Anemia (a condition in which your body does not have enough healthy red blood cells, due to a lack (deficiency) of vitamin B12) . Muscle weakness (generalized) . Benign Prostatic Hyperplasia ( condition in which an overgrowth of prostate tissue pushes against the urethra and the bladder, blocking the flow of urine) with lower urinary tract symptoms (hesitancy, poor and/or intermittent stream, straining, feeling of incomplete bladder emptying, dribbling, etc.) . The admission record did not indicate Resident 108 had no teeth and had lost his dentures.
During a review of Resident 108's Minimum Data Set (MDS- a resident assessment tool used to identify resident care needs) - Version 3.0 Resident Assessment and Care Screening, dated 9/22/21, indicated, Resident 108 has the ability to express ideas and wants and had a Brief Interview of Mental Status (BIMS- The total possible BIMS score ranges from 00. to 15. 13 - 15: cognitively intact. 08 - 12: moderately impaired. 00 - 07: severe impairment) score of 10, indicating moderately impaired.
During a concurrent observation and interview on 10/7/21, at 11:50 a.m., with Resident 108, in his room, Resident 108 had no teeth and no dentures at bed side. Resident 108 stated he does not have any teeth and does not have his dentures here, they (the facility staff) do not offer oral care to me nor have they since I have been here.
During a review of Resident 108's Care Plan (CP) titled, [name of resident] has oral/dental health problems (missing teeth r/t (related to) Poor dentition), date initiated 9/18/21, the CP indicated, Goal The resident will be free of infection, pain or bleeding in the oral cavity by review date . interventions/Tasks Coordinate arrangements for dental care, transportation as needed/as ordered . [resident's name] requires mouth inspections q shift [every shift] during oral cares. Report changes to the nurse . Monitor/document/report PRN [as needed] any s/sx [signs and symptoms] of oral/dental problems needing attention: Pain (gums, toothache, palate), Abscess, Debris in mouth, Lips cracked or bleeding, Teeth missing, loose, broken, eroded, decayed, Tongue (black, coated, inflamed, white, smooth), Ulcers in mouth, Lesions . Provide mouth care as per ADL [activities of daily living] personal hygiene .
During an interview on 10/11/21, at 9:26 a.m., with the Director of Staff Development/ Infection Preventionist (DSD/IP), the DSD/IP stated, We [the facility] offer oral care to residents . the DON [Director of Nursing] does the bulk of the care planning, the nurses do some once in a while and I help occasionally too. DSD/IP was observed checking her three education binders and stated she was unable to locate any education she had provided to staff on oral care. DSD/IP stated it is important for residents to have oral care to prevent decay, sores, and infection; all these issues can affect the resident's ability to eat.
During a concurrent observation and interview on 10/13/21, at 12:29 p.m., with Certified Nursing Assistant/Sitter (CNA/S) in Resident 108's room, CNA/S was seen helping Resident 108 with his lunch. Resident 108 was sitting up in bed and his hands were shaking. CNA/S stated she has been a sitter for Resident 108 on four different days, I assist him with eating and drinking, help him to the bathroom, get dressed and help keep him safe. CNA/S stated she does not look at the residents care plan and she has not looked in Resident 108's mouth, I was not aware that I should inspect the residents (Resident 108's) mouth at least once a shift and let the nurse know if there are any issues. CNA/S pulled out Resident 108's mouth wash from her pocket and stated, I have offered it to him and will offer it again.
During a concurrent interview and record review on 10/13/21, at 1 p.m., with Licensed Vocational Nurse (LVN) 6, Resident 108's care plans were reviewed. LVN 6 stated she was not aware that Resident 108 had a care plan for his mouth. LVN 6 stated, I look at the care plans for residents at least once daily . I was not aware that we should be checking his (Resident 108's) mouth every shift. LVN 6 stated it is very important to monitor his mouth for signs and symptoms of infection. LVN 6 confirmed the care plan had not been followed.
During a review of the facility's policy and procedure (P&P), titled, Mouth Care, dated 10/2010, the P&P indicated, .Purpose The purpose of this procedure are to keep the resident's lips and oral tissues moist, to cleanse and freshen the resident's mouth, and to prevent infections of the mouth. Preparation 1. Review the resident's care plan to assess for any special needs of the resident .
During a professional reference review the Centers for Disease Control and Prevention, last updated 11/3/2020, article titled, Oral Health, was reviewed. The Oral Health article indicated, . Oral health is essential to general health and well-being. Oral disease can cause pain and infections that may lead to problems with eating, speaking, and learning. It can also affect social interaction . the three oral conditions that most affect overall health and quality of life are cavities, severe gum disease, and severe tooth loss . Tobacco use and diabetes are two risk factors for gum disease .
During a review of the facility's P&P, titled, Care Plans - Comprehensive dated 9/2010, indicated, .An individualized comprehensive care plan that is measurable objective and timetables to meet resident's medical, nursing, mental and psychological needs is developed for each resident .1. Our facility's Care Planning .care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. 2. The comprehensive care plan is based on a thorough assessment that is not limited to the MDS. 3. Each resident's comprehensive care plan is designed to: a. Incorporate identified problem areas; b. Incorporate risk factors associated with identified problems .f. Identify professional services that are responsible for each element of care .9. The Care Planning/Interdisciplinary Team (IDT) is responsible for the review and updating of the care plans: a. When there has been a significant change in resident's condition .d. At least quarterly .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to assess one of three sampled residents (Resident 108) for removal of an indwelling (tube left within a body organ) foley catheter placed after admission.
This failure resulted in pain to Resident 108's penis and the potential harm of continued infection and discomfort.
Findings:
During a review of Resident 108's Face Sheet (document that contains residents name, date of birth , room number, resident representative, diagnoses, insurance information and more) titled, admission RECORD, dated 10/5/21 at 3:44 p.m., indicated, .Resident 108 was admitted on [DATE] for Apraxia (Difficulty with skilled movements even when a person has the ability and desire to do them) following unspecified Cerebrovascular Disease (a group of conditions that affect blood flow and the blood vessels in the brain) . Acute Kidney Failure (A condition in which the kidneys suddenly can't filter waste from the blood.) . Type 2 Diabetes (A chronic condition that affects the way the body processes blood sugar.) with Diabetic Nephropathy (deterioration of kidney function) . Conversion disorder (a medical condition in which the brain and body's nerves are unable to send and receive signals properly) with seizures (a sudden, uncontrolled electrical disturbance in the brain) . Essential hypertension (high blood pressure that has no clearly identifiable cause) . Vitamin B 12 Deficiency Anemia (a condition in which your body does not have enough healthy red blood cells, due to a lack (deficiency) of vitamin B12) . Muscle weakness (generalized) . Benign Prostatic Hyperplasia ( condition in which an overgrowth of prostate tissue pushes against the urethra and the bladder, blocking the flow of urine) with lower urinary tract symptoms (hesitancy, poor and/or intermittent stream, straining, feeling of incomplete bladder emptying, dribbling, etc.) . The admission record did not indicate Resident 108 was admitted with an indwelling catheter.
During a review of Resident 108's Minimum Data Set (MDS- a standardized, primary screening and assessment tool of health status of a resident)- Version 3.0 Resident Assessment and Care Screening, dated 9/22/21, indicated, Resident 108 has the ability to express ideas and wants and had a Brief Interview of Mental Status (BIMS- test to see how well a resident is functioning cognitively (remembering, thinking, and reasoning- The total possible BIMS score ranges from 00. to 15. 13 - 15: cognitively intact. 08 - 12: moderately impaired. 00 - 07: severe impairment) score of 10, indicating moderately impaired.
During a concurrent interview and clinical record review of Resident 108's electronic health record (EHR), on 10/7/21, at 9:30 a.m., with Licensed Vocational Nurse (LVN) 4, the EHR indicated Resident 108 was admitted on [DATE] to the facility and on 9/18/21 resident sustained a fall and was sent to the hospital for pain in his left hip and right knee,. LVN 4 stated during this visit the hospital checked him for a urinary tract infection and this is when the hospital placed the foley catheter. Review of Resident 108's hospital Emergency Department (ED) discharge instructions, dated [DATE], indicated, . Reason for Visit: Chief Complaint: S/P (status post or after) Fall C/O (complains of) Left hip pain Diagnosis: 1) Right knee contusion (a bruise). 2) Left Hip Contusion . Activity: Activity as tolerated Additional Instructions: Rest. Ice packs to the right knee and left hip. Take Tylenol for pain. See her [his sic] regular doctor in 2-3 days. Resume your regular medications. Return to the emergency room if any problems or concerns . LVN 4 stated, there was no mention of foley catheter being placed at this hospital visit and there was no order to keep the foley catheter in. LVN 4 stated, she was not working the day he returned from the hospital and when she returned LVN 4 assumed the physician was aware of the foley catheter and there was an order for the foley catheter. LVN 4 confirmed, there was an order to keep the foley catheter dated 9/26/21 by the primary physician [name], 8 days after LVN 4 stated he came back to the facility from the hospital. LVN 4 confirmed there was no physician note on 9/26/21 indicating the physician assessed the resident for the foley catheter. LVN 4 stated, if she received a resident back from the hospital with a foley catheter she would have contacted the hospital for a reason and order to keep the foley and then contacted the primary physician at her facility to let them know and obtain an order for the foley from him. LVN 4 stated Resident 108 was not admitted with a foley catheter. LVN 4 stated she does not know why a trial removal was not done for this resident's foley. LVN 4 stated having the foley places the resident at higher risk of getting an infection.
During a review of Resident 108's EHR on 10/7/21, at 10:05 a.m., the EHR did not include documented evidence the physician for Resident 108 was informed of the indwelling catheter.
During a concurrent observation and interview on 10/7/21, at 11:35 a.m., with Resident 108, in his room, Resident 108 was observed in a contact isolation (used when a patient has an infectious disease that may be spread by touching either the patient or other objects the patient has handled) room with a staff member sitting outside the door. Resident 108 was laying in his bed on his right side facing the door. Resident 108 stated his foley catheter was hurting. LVN 4 was observed in gown, gloves, and surgical mask pull Residents 108's privacy curtain and asked the resident if it was okay for her to look at the foley catheter. Resident 108 stated yes it was okay and turned onto his left side. LVN 4 pulled back his blanket and Resident 108's catheter was observed not secured to his leg to prevent pulling and Resident 108's penis appeared slightly reddened along the inside of his groin. LVN 4 assessed the catheter with her gloved hands and his penis and said it did not seem like anything is wrong. Resident 108 stated, there's never anything wrong when I tell them it hurts or is uncomfortable . I have not received pain medication for the pain, I don't ask for it because it does not work, and they do not offer.
During an interview on 10/7/21, at 11:40 a.m., with LVN 4, LVN 4 stated, Resident 108 always complained that the foley catheter was bothering him but when assessed there was nothing identified that was wrong.
During a concurrent observation and interview on 10/7/21, at 11:55 a.m., with Resident 108, while in his room , Resident 108 stated, am I wet? When Resident 108 pulled back his blankets, a flow of urine was observed around the catheter and his shirt and bed padding were visibly getting wet. Resident 108 requested assistance to get cleaned up. CNA went to inform LVN 4 about the urine leaking around the catheter. Two minutes later the CNA came in and cleaned Resident 108 up. Afterwards LVN 4 came in stating she had an order from the physician to take out Resident 108's foley catheter and she asked for Resident 108's permission and he allowed her to remove it. Resident 108 stated he felt better once it was out.
During a review of Resident 108's ED (Emergency Department) Nurses Note, dated 9/20/21, at 8:30 a.m., the note indicated, . Placed Foley catheter to collect urine as patient unable to urinate and has retention of urine. Foley catheter placed and 500 ml (milliliters-unit of measure) noted in bag .
During a review of Resident 108's ED Nurses Note, dated 9/20/21, at 11:31 a.m., the note indicated, .Patient discharged back to SNF [skilled nursing facility], report given to LVN 5, patient awake and alert, no distress, home in good disposition. Patient transferred back to SNF with foley catheter as per Dr. [name] order .
During a review of Resident 108's Medication Administration Record (MAR), dated 10/2021, the MAR indicated Resident 108 had an order for Tylenol Tablet 325 MG (milligrams- unit of measure) (Acetaminophen) Give 2 tablet by mouth every 4 hours as needed for Pain: Mild . Start dated 09/13/2021. The MAR indicated, Tylenol was not administered during the month of October. The MAR indicated, .Pain assessment Q (every) shift: Observe/ask resident if having pain every shift -Start Date- 09/10/2021 . The MAR indicated from 10/1/21 through 10/10/21 Resident 108 has had no pain.
During a review of Resident 108's Care Plan titled, The resident has a foley Catheter, Date Initiated: 10/04/2021 Revision on: 10/04/2021 Goal The resident will be/remain free from catheter-related trauma through review date . Interventions/Tasks . Monitor for s/sx (signs and symptoms) of discomfort on urination and frequency . Monitor/document for pain/discomfort due to catheter .
During a review of the facility's policy and procedure (P&P) titled, Catheter Care, Urinary, revised September 2014, indicated, . The purpose of this procedure is to prevent catheter-associated urinary tract infections . Changing Catheters . 2. Ensure that the catheter remains secured with a leg strap to reduce friction and movement at the insertion site. (Note: Catheter tubing should be strapped to the resident's inner thigh.) . Documentation The following should be recorded in the resident's medical record: 5. Any problems noted at the catheter-urethral junction during perineal care such as drainage, redness, bleeding, irritation, crusting, or pain. 6. Any problems or complaints made by the resident related to the procedure. 7. How the resident tolerated the procedure.
During a review of the Centers for Disease Control and Prevention (CDC) website under Infection Control a document titled, GUIDELINE FOR PREVENTION OF CATHETER ASSOCIATED URINARY TRACT INFECTIONS 2009, last updated June 6, 2019, was reviewed, it indicated, . I. Appropriate Urinary Catheter Use A. Insert catheters only for appropriate indications . and leave in place only as long as needed . 1. Minimize urinary catheter use and duration of use in all patients, particularly those at higher risk for CAUTI or mortality from catheterization such as women, the elderly, and patients with impaired immunity . 2. Avoid use of urinary catheters in patients and nursing home residents for management of incontinence . a. Further research is needed on periodic (e.g., nighttime) use of external catheters (e.g., condom catheters) in incontinent patients or residents and the use of catheters to prevent skin breakdown . II. Proper Techniques for Urinary Catheter Insertion . E. Properly secure indwelling catheters after insertion to prevent movement and urethral traction . Retrieved from: https://www.cdc.gov/infection control/guidelines/cauti/.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the Minimum Data Set (MDS- a resident assessment tool used to identify resident care needs) assessment accurately reflected the resident's current status for five (5) of 16 sampled residents (Residents 110, ,114, 117, 122, and 128) when:
1. Resident 114's MDS assessment for weight loss were not coded accurately.
2. Residents 110, 117, 122, and 128's MDS assessment for the influenza (A common viral infection that can be deadly, especially in high-risk groups) and Pneumococcal vaccines (Vaccine to prevent pneunomia (Infection that inflames air sacs in one or both lungs, which may fill with fluid.) were not coded accurately.
3. Resident 128's MDS assessment for falls since admit were not coded accurately.
These failures had the potential for the facility to not provide the necessary care and services to meet the resident's individualized needs and placed them at risk for decline in health and safety.
Findings:
1. During a concurrent interview and record review, on 10/7/21 at, 3:14 p.m., with the Director of Nurses (DON), the MDS dated [DATE] for Resident 114 was reviewed. The DON stated the residents were weighed at the beginning of the month. The DON stated a weight loss of 2.5 pounds was supposed to be reported to the Registered Dietician (RD) and herself. The DON stated the RD was supposed to follow up with an assessment when this was reported but the facility did not have an RD at that time. The weights from 5/7/21 to 10/7/21 were reviewed with the DON. Resident 114 weighed 120 pounds on admission 5/7/21, 116 pounds on 6/2/21, 116.4 pounds on 7/1/21, 116 pounds on 8/6/21, 111.6 pounds on 9/3/21, and 109.6 pounds on 10/1/21. The DON stated this was a severe weight loss and should have triggered a new MDS assessment but had not. The DON stated the RD was supposed to follow up with an assessment when this was reported but the facility did not have an RD at that time. The DON stated Resident 114 had lost 10.5 pounds which was a 7.5% weight loss in 5 months. The DON stated the MDS dated [DATE], under Nutritional Status, section K0300 indicated, Weight Loss .0 . no weight loss. The DON stated the MDS for Resident 114 Nutritional Status was not correct. The DON was unable to find any nursing notes on Resident 114's weight loss. The DON stated the nurses should have documented, called the doctor and the RD but had not. The DON stated there were a lot of errors on the MDS because the facility used a consultant MDS nurse, and she did the assessments remotely. The DON stated Resident 114 did not have a weight loss care plan because the MDS assessment was wrong. The DON stated the MDS assessments needed to be accurate to indicate what care the residents need. The DON stated Resident 114 could have experienced anemia, dehydration, or electrolyte balance from the significant weight loss. The DON stated the weight loss for Resident 114 was preventable. The DON stated the severe weight loss should have triggered the MDS. See (F692) for complete weight loss details
During a concurrent interview and record review on 10/08/21 at 10:31 a.m., with Licensed Vocational Nurse (LVN) 2, LVN 2 reviewed the weights on the electronic documentation system used by the facility. LVN 2 stated the Certified Nursing Assistants (CNAs) weighed the residents. LVN 2 stated the CNAs did not report the weights to the LVNs but give them to the DON. LVN 2 stated she thought the DON liked doing the weight reviews. LVN 2 stated the Nurses or DON should have called the doctor for a significant weight loss and made a care plan with the RD. LVN 2 stated sometimes the DON would instruct the LVNs to call the doctor or make a care plan but she usually did it herself. LVN 2 stated Resident 114 could have experienced further weight loss or become ill because no care plan was made, the doctor was not notified, and nutritional supplements were not ordered.
During a review of Resident 114's Face Sheet (document that contains residents name, date of birth , room number, resident representative, diagnoses, insurance information and more) dated 10/7/21, the Face Sheet indicated the admission date was 5/7/21. The Face Sheet indicated Resident 114 had diagnosis of Dementia (memory impairment), Bipolar Disorder (mental condition marked by periods of elation and depression), Major Depressive Disorder (chronic sadness), Psychotic Disorder (chemical imbalance in the brain marked by seeing or hearing things that are not there), Sleep Disorder (unable to sleep at regular times), Muscle Wasting (weakness and shrinking in the muscles), and Hypertension (higher than normal pressure in the blood vessels).
2. During a concurrent interview and record review, on 10/11/21, at 4:11 p.m., with the DON, Resident 110's MDS, dated [DATE], was reviewed. Resident 110's MDS indicated, in Section O for immunizations under Influenza response was No reason 1. Resident not in the facility during this influenza season. The DON stated Resident 110 was admitted on [DATE] so the MDS was marked correctly. The DON confirmed the MDS for Resident 110 indicated the Pneumococcal vaccine was not offered. The DON stated Resident 110 should have been offered the Pneumococcal vaccine. The DON stated, It looks like the MDS LVN (Licensed Vocational Nurse- who is responsible for filling in the MDS for the residents) was just coding no and not offered instead she should have investigated further. Laziness.
During a concurrent interview and record review, on 10/11/21, at 4:11 p.m., with the DON, Resident 117's MDS, dated [DATE], was reviewed. Resident 117's MDS indicated, in Section O for immunizations under Influenza response was No reason 9. None of above. The DON stated Resident 117 was admitted on [DATE] so the MDS should have been marked 1. Resident not in the facility during this influenza season. The DON confirmed the MDS for Resident 117 indicated the Pneumococcal vaccine was not offered. The DON stated Resident 117 should have been offered the Pneumococcal vaccine, the wife (for Resident 117's) calls every month and has been more than happy for him to get his immunizations. I don't know why dates are not put in or why it wasn't offered.
During a concurrent interview and record review, on 10/11/21, at 4:11 p.m., with the DON, Resident 122's MDS, dated [DATE], was reviewed. Resident 122's MDS indicated, in Section O for Immunizations under Influenza response was No that resident had not received it, with a reason of 9. None of the above. The DON stated influenza for Resident 122 should have been marked 1. Resident not in the facility during this influenza season, Resident 122 was admitted on [DATE]. The DON confirmed the MDS for Resident 122 indicated that the Pneumococcal vaccine was not offered and gave no reason why. The DON confirmed that Resident 122 received the Pneumococcal vaccine Dose 1 on 7/13/21 and that the MDS dated [DATE] was incorrect.
During a concurrent interview and record review, on 10/11/21, at 4:11 p.m., with the DON, Resident 128's MDS, dated [DATE] was reviewed. Resident 128's MDS indicated, in Section O for Immunizations under Influenza response was No that resident had not received it, with a reason of 9. None of the above. The DON stated the Resident 128 was admitted on [DATE] so the correct response should have been 1. Resident not in the facility during this influenza season. The DON confirmed for Section O0300 for the Pneumococcal vaccine Resident 128's MDS is marked 0. For No and reason 3. Not offered. The DON stated Resident 128 should have been offered the Pneumococcal vaccine and the facility should have asked her resident representative (RP) if she was not able to make decisions for herself.
During an interview on 10/8/21, at 3:27 p.m., with MDS LVN, the MDS LVN stated she worked remotely and came into the facility monthly to assess the residents. The MDS LVN stated she obtained the information for residents from their electronic health care records and from the residents and staff. The MDS LVN stated, I understand that coding correctly is very important, not sure what happened. I have a plan to fix these issues for further assessments. The MDS LVN stated for Resident 128 the vaccines were not offered because the resident did not have consent in her medical records; for Resident 122 the vaccine was historical 7/13/21; for Resident 110 MDS was coded incorrectly and she ha corrected it.
3. During a review of Resident 128's Face sheet titled, admission Records, dated 10/5/21, at 3:45 p.m., indicated, .Resident 128 was admitted on [DATE], with the diagnoses of Heart Failure (the heart cannot pump or fill adequately), Chronic Obstructive Pulmonary Disease (A group of lung diseases that block airflow and make it difficult to breathe.), Malnutrition (not consuming enough protein and calories), Osteoporosis (A condition in which bones become weak and brittle.), muscle weakness, and Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment) .
During an interview on 10/11/21, at 6:55 a.m., with MDS Licensed Vocational Nurse Coordinator (MDS LVN), the MDS LVN stated Resident 128's MDS was still in progress and that she had just updated it. MDS LVN stated, I get my information for Fall and changes in our meeting we have weekly and also at the risk management section.
During a concurrent interview and record review, on 10/11/21, at 4:15 p.m., with the DON, Resident 128's MDS, dated [DATE] was reviewed. Resident 128's MDS indicated, under section J1800 states 0. No to falls since admit and section J1900 is not filled in which asked the number of falls since admit. Review of Resident 128's Electronic Health Records (EHR) for Resident 128's admission 5/13/21, with the DON, indicate Resident 128 had three falls between 5/13/21 and 8/17/21. The DON stated Resident 128 had two of these falls within the first couple of weeks after she was admitted . The DON confirmed that the MDS dated [DATE] was inaccurate and would contact the MDS Licensed Vocational Nurse who was responsible for filling in the residents' MDS. The DON stated, It is important to get an accurate picture of what has happened to the resident, in order to care for the resident's needs. The DON stated the expectation is that the MDS LVN will fill in the MDS accurately.
During a review of the Centers for Medicare & Medicaid Services, Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.17.1 October 2019. The RAI process indicated, . 1. The assessment accurately reflects the resident's status . In addition, an accurate assessment requires collecting information from multiple sources, some of which are mandated by regulations. Those sources must include the resident and direct care staff on all shifts, and should include the resident's medical record, physician, and family, guardian, or significant other as appropriate or acceptable. It is important to note here that information obtained should cover the same observation period as specified by the MDS items on the assessment, and should be validated for accuracy (what the resident's actual status was during that observation period) by the IDT completing the assessment .
During a review of the facility's policy and procedure titled, MDS Error Correction dated 9/2010, indicated, .Major changes in the resident's status may prompt a Significant Change in Status Assessment .If an erroring data is discovered .The correction is made to the hard copy .The resident's care plan is reviewed and modified .A major error is one that inaccurately reflects the resident's clinical status and/or may result in inappropriate plan of care .
During a review of the facility's policy and procedure titled, Care Area Assessments dated 5/2011, indicated, .Care Area Assessments (CAAs) will be used to help analyze data obtained from the MDS and to develop individualized care plans .Triggered care areas will be evaluated by the interdisciplinary team .Identify areas of concern .Doing an in-depth, resident specific assessment of the triggered condition .Define the problem .Make decisions about the care plan .Document interventions .Include recommendations for monitoring .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one of 16 sampled residents (Resident 114) maintained acceptable parameters of nutritional status when:
1. Licensed nurses did not communicate two episodes of significant severe unplanned weight loss to the interdisciplinary team (IDT - members of the care team that include nurses, social workers, doctors, therapists, dietician and others). Licensed nurses documented Resident 114's weight loss of 8.6% between 5/7/21 and 8/6/21 and a weight loss of 10.2% between 5/7/21 and 10/1/21 and did not report this to the IDT and appropriate assessments and effective interventions were not implemented.
2. The Registered Dietician (RD) did not conduct a nutritional assessment to address the significant severe unplanned weight loss of 8.6% within a three-month timeframe from 5/7/21 to 8/6/21 and the significant severe unplanned weight loss of 10.2 % within a five-month timeframe from 5/7/21 to 10/1/21 for Resident 114 in accordance with the facility's policy and procedure.
As a result of these failures, Resident 114's compromised nutritional status was not addressed which could lead to further medical complications.
Findings:
1. A review of Resident 114's Medical Record (MR), dated 10/8/21, indicated, Resident 114 was admitted on [DATE], with diagnoses that included Unspecified Dementia with Behavioral Disturbance (diminished memory with episodes of agitation or restlessness), Bipolar Disorder (feeling very sad or very excited), Circadian Rhythm Sleep Disorder (unable to sleep), Major Depressive Disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), Hyperlipidemia (elevated fat levels in the body), Muscle Weakness, Muscle Wasting and Atrophy (decreased muscle tissues), Psychotic Disorder with Delusions (a disorder characterized by a disconnection from reality) and Essential Hypertension (abnormally high blood pressure).
The most recent Minimum Data Set (MDS, a resident assessment tool) dated 8/18/21, indicated a BIMS (brief interview for mental status) score of 9 out of a possible 15, indicating Resident 114 was unable to complete the interview. Section C1000 of the MDS indicated, Resident 114's Cognitive Skills for Daily Decision Making was severely impaired.
Section K of the MDS indicated, Resident 114 had a weigh loss of 5% or more in the last month and was not on a physician- prescribed weight-loss regimen.
A review of the facility document titled, Weights and Vitals Summary (WVS), dated 10/8/21, indicated the following weights and comparisons for Resident 114:
5/7/21
121.2 lbs (pounds., unit of measurement)
5/9/21
120 lbs
5/15/21 122.1 lbs
5/23/21 118.8 lbs [-3.3. lbs in one week]
5/29/21 117.8 lbs
6/2/21
116 lbs
6/6/21
117 lbs
7/1/21
116.4 lbs
8/6/21
111.6 lbs (-7.5% change [comparison weight 5/15/21, 122.1 lbs., -8.6%, -10.5 lbs.]
9/3/21
111.6 lbs
10/1/21 109.6 lbs (-10% change [comparison weight 5/15/21, 122.1 lbs., -10.2%, -12.5lbs.]
A review of the facility document titled Order Summary Report (OSR), dated 10/8/21, indicated, on 5/07/21 a Regular diet, Regular texture, and Regular Liquids Consistency was ordered by the Physician for Resident 114.
A review of the facility document titled, History and Physical (H&P), dated 5/9/21, 6/17/21, and 8/31/21 for Resident 114 completed by the Physician indicated the section titled, Physical Findings, WT [weight] was not documented.
A review of the facility document titled, 30-day Evaluation - Monthly dated 7/13/21 and 9/1/21 for Resident 114 completed by the Physician indicated VS [Vital Signs] WNL [Within Normal Limits]. Exam unchanged.
During a concurrent interview and record review, on 10/07/21 at 12:44 p.m., with the Licensed Vocational Nurse (LVN) 1, Resident 114's Weights and Vitals Summary (WVS), dated [DATE] was reviewed. The LVN 1 stated, all newly admitted residents were weighed every week for four weeks and if stable, then weighted monthly. The LVN 1 stated, she would ask the Certified Nurse Assistant (CNA) to reweigh the resident for any weight loss. The LVN 1 stated, she would notify the doctor, the RD, the dietary department, and the responsible party (RP) for any significant or severe weight loss. The WVS indicated, on 5/15/21, Resident 114's weight was 122.1 lbs. On 8/6/21, Resident 114 weight was 111.6 lbs., a 10.5 lb., 8.6% weight loss in three months. On 10/1/21, Resident 114's weight was 109.6 lbs., a 12.5 lb., 10.2% weight loss in five months. The LVN 1 was unable to confirm nursing documentation in Resident 114's medical record which indicated the Physician, the RD, the dietary department, and the RP were notified when Resident 114 experienced an 8.6% significant severe unplanned weight loss in three months and when Resident 114 experienced a 10.2% significant severe unplanned weight loss in five months.
During a concurrent interview and record review, on 10/07/21 at 12:55 p.m., with LVN 1, Resident 114's Care Plan (CP), initiated on 5/11/21, was reviewed. The Focus Section of the CP indicated, the RD admission Assessment was completed on 5/13/21. The interventions/tasks section of the CP indicated, monitor/record/report to MD PRN signs and symptoms (s/s) of malnutrition: Emaciation (Cachexia), muscle wasting, significant weight loss: 3 lbs. in one week, >5% in one month, >7.5% in three months, >10% in six months. Provide, serve diet as ordered. Monitor intake and record every meal.
During a concurrent interview and record review, on 10/07/21 at 1:00 p.m., with the LVN 1, Resident 114's Progress Notes (PN), were reviewed. The LVN 1 was unable to confirm documentation the physician was notified for s/s of malnutrition: Emaciation (Cachexia), muscle wasting, significant weight loss: 3 lbs. in one week, >5% in one month, >7.5% in three months, >10% in six months.
During a concurrent interview and record review, on 10/07/21 at 1:15 p.m., with the LVN 1, Resident 114's CP, initiated on 5/11/21, was reviewed. The CP indicated, Resident 114's has the potential nutritional problem related to Diet restrictions. The LVN 1 was unable to confirm Resident 114's care plan was updated to address the significant unplanned weight loss of 3.3 lbs. in a week on 5/23/21, 10.5 lbs., 8.6% in three months, from 5/15/21 through 8/16/21, and a significant unplanned weight loss of 12.5 lbs, 10.2% in five months, from 5/15/21 through 10/1/21.
During a concurrent interview and record review on 10/7/21 at 3:07 p.m., with the Director of Nursing (DON), the WVS and the PN, dated 10/7/21 for Resident 114 were reviewed. The DON stated, all newly admitted residents were weighed every week for four weeks and if stable, were weighed monthly. The DON confirmed Resident 114 experienced a significant severe unplanned weight loss of 10.5 lbs, 8.6% in three months, from 5/15/21 through 8/16/21 and a significant severe unplanned weight loss of 12.5 lbs, 10.2% in five months, from 5/15/21 through 10/1/21. The DON stated, Resident 114's significant severe unplanned weight loss could result in further medical complications including anemia, electrolyte imbalance, dehydration, kidney failure, and further weight loss.
The DON was unable to confirm nursing documentation in Resident 114's medical record which indicated the Physician, the RD, the dietary department, and the RP were notified when Resident 114 experienced a significant severe unplanned weight loss of 10.5 lbs, 8.6% in three months, from 5/15/21 through 8/16/21 and a significant severe unplanned weight loss of 12.5 lbs, 10.2% in five months, from 5/15/21 through 10/1/21.
Resident 114's CP, initiated on 5/11/21 was reviewed with the DON. The CP indicated, Resident 114's has the potential nutritional problem related to Diet restrictions. The DON was unable to confirm Resident 114's care plan was updated to address the significant unplanned weight loss of 3.3 lbs. in a week on 5/23/21, 10.5 lbs., 8.6% in three months, from 5/15/21 through 8/16/21 and a significant unplanned weight loss of 12.5 lbs, 10.2% in five months, from 5/15/21 through 10/1/21. The DON stated, licensed nurses should update the care plan to address the weight loss or create a new care plan for new problems. The DON stated, Resident 114's significant unplanned weight loss could result in further medical complications including anemia, electrolyte imbalance, dehydration, kidney failure, and further weight loss.
During a concurrent interview and record review, on 10/7/21, at 3:07 p.m., with the DON, the facility documents titled IDT Weight Management Assessment (IDT-WMAU), dated 5/25/21, 6/4/21, 6/9/21, and 6/15/21 for Resident 114, were reviewed. Section A of the IDT-WMAU dated 5/25/21 indicated, Resident 114 was on a regular diet and tolerated well. Resident 114 lost 3.3# in a week. PO intake was 58%. She eats in her room and is able to feed herself. Continue to monitor weekly weights. Intake 25% to 75%. Section B of the IDT-WMAU indicated, Recommendations: Current Plan of Care remains appropriate, no changes needed at this time. The IDT-WMAU was completed by the the DM 1. The DM 1, SSD, AD, and DSD attended the IDT meeting. The DON confirmed the IDT-WMAU.
The IDT Weight Management Assessment (IDT-WMAU), dated 6/4/21 for Resident 114, indicated for Section A, Resident 114 was on a regular diet and tolerated well. Resident 114 lost 3.3# in a week. PO intake was 58%. She eats in her room and is able to feed herself. Continue to monitor weekly weights. Intake 75% to 100%. Section B of the IDT-WMAU indicated, Recommendations: Current Plan of Care remains appropriate, no changes needed at this time. The IDT-WMAU was completed by the DM 1. The DM 1, SSD, AD, and DSD attended the IDT meeting. The DON confirmed the IDT-WMAU.
The IDT Weight Management Assessment (IDT-WMAU), dated 6/9/21 for Resident 114, indicated for Section A, Resident 114 was on a regular diet and tolerated well. Resident 114 lost 0.8# in a week. PO intake was 79%. She eats in her room and is able to feed herself. Continue to monitor weekly weights. Intake 75% to 100%. Section B of the IDT-WMAU indicated no changes needed. The IDT-WMAU was completed by DM 1. The DM 1, SSD, AD, and DSD attended the IDT meeting. The DON confirmed the IDT-WMAU.
The IDT Weight Management Assessment (IDT-WMAU), dated 6/15/21 for Resident 114, indicated for Section A. Resident 114 was on a regular diet and tolerated well. Resident 114 lost 0.4# in a week. PO intake was 72%. She eats in her room and is able to feed herself. Weight was stable, continue to monitor weights monthly. Intake 50% to 100%. Section B of the IDT-WMAU indicated, Recommendations: Current Plan of Care remains appropriate, no changes needed at this time. The IDT-WMAU was completed by DM 1. The DM 1, SSD, AD, and DSD attended the IDT meeting. The DON was unable to confirm further IDT-WMAU meetings were conducted after 6/15/21.
During an interview on 10/7/21, at 5:24 p.m., with the LVN 3, the LVN 3 stated, Resident 114 fed herself, refused help, and frequently paced the hallway.
During a concurrent observation and interview inside Resident 114's room, on 10/7/21, at 5:30 p.m., with the CNA 3, the CNA 3 stated, Resident 114 fed herself, had good and bad days. The CNA 3 stated, she would offer a sandwich or something else if Resident 114 consumed 25% or less of her meals.
During an observation of the dinner meal service on 10/7/21, at 5:35 p.m., in Resident 114's room, Resident 114 was observed struggling to cut the chicken meat with a fork. Resident 114 used her hands to eat the chicken meat. Resident 114 consumed 90% of chicken, 75% of rice, 75% of vegetable and 100% of dessert. Resident 114 did not drink the milk. Resident 114 attempted to remove the water pitcher cover to drink water, however she was unable to remove the water pitcher cover. The CNA 3 assisted Resident 114 to remove the water pitcher cover and Resident 114 drank water directly from the pitcher.
During an interview on 10/7/21, at 5:51 p.m., with the LVN 1, the LVN 1 stated, she was not notified or aware of any change in intake or weight loss for Resident 114.
During an interview on 10/8/21 at 10:16 a.m., with the RD 1, the RD 1 stated, he started working at the facility two weeks ago. The RD 1 stated the facility had a loose system for monitoring weights. The RD 1 stated, there was not much communication between nursing and the RD or dietary department. The RD 1 stated, the CNAs were responsible for weighing residents weekly and monthly. The CNAs notified the licensed nurses of the weekly and monthly weights. The licensed nurses were responsible to enter the resident's weights in the electronic medical record. The RD 1 stated, the licensed nurses were responsible to notify the RD of any significant weight change. The RD 1 further stated the facility's goal was to manage resident's weight loss proactively.
On 10/8/21, at 11:55 a.m., an observation of Resident 114 was conducted. Resident 114 was observed walking slowly with a steady gait, wearing a loose blue upper garment, loose pants, and a pair of slippers. When Resident 114 was asked in her native language how she was doing, Resident 114 stated she was hungry.
During a concurrent observation and interview on 10/8/21, at 12:05 p.m., with the CNA 4 outside Resident 114's room, the CNA 4 stated, Resident 114's upper and lower garments were loose and looked too big for her.
During a concurrent observation and interview on 10/8/21, at 12:33 p.m., with the CNA 5 inside Resident 114's room, the CNA 5 stated, Resident 114 was on a regular diet and needed assistance with tray set-up. The CNA 5 set-up Resident 114's meal tray and Resident 114 begin eating her meal vigorously. CNA 5 stated, Resident 114 liked to be left alone during mealtimes.
Upon completion of Resident 114's lunch meal, on 10/8/21, at 12:51 p.m., Resident 114 consumed 100% of the fish, gelatin, and dinner roll. Resident 114 consumed 75% of the french fries and 25% of the cabbage salad. Resident 114 drank 100% (240 ml) of milk.
During a concurrent observation and interview on 10/8/21, at 1:19 p.m., with the CNA 6, the CNA 6 stated, Resident 114 consumed 100% of her lunch meal and drank 100% of her milk. CNA 6 validated Resident 114 didn't eat 100% of her cabbage salad.
During an interview on 10/8/21, at 3:48 p.m., with the RD 1, the RD 1 confirmed the significant severe unplanned weight loss of 8.6% within a three-month timeframe from 5/7/21 to 8/6/21 and the significant severe unplanned weight loss of 10.2 % within a five-month timeframe from 5/7/21 to 10/1/21 for Resident 114 was not addressed by the RD. The RD 1 further stated the weight loss for Resident 114 was not acceptable.
During an interview on 10/11/21 at 1:47 p.m., with the CNA 7, the CNA 7 stated, the diet ordered for Resident 114 had not changed since admission. The CNA 7 stated, Resident 114's weights were taken every month by the RNA (Restorative Nurse Assistant) or CNA and reported to the charge nurse.
During a concurrent interview and record review on 10/12/21 at 1:25 p.m., with the DSD, Resident 114's Meal Percentage Report Documentation Survey Reports (MPR), dated 8/1/2021 through 10/7/21 were reviewed. The MPR indicated, of the 204 meals (breakfast, lunch, and dinner), served between 8/1/21 and 10/7/21, Resident 114 refused of her meals 9% of the time and consumed 50% or less 21% of the time. The DSD confirmed Residents 114's intake.
During a review of the facility's policy and procedure (P&P) titled, Weight Assessment and Intervention, dated September 2020, the P&P indicated, Weight Assessment .1. The nursing staff will measure resident weights on admission, the next day, and weekly for four weeks thereafter. If no weight concerns are noted at this point, weights will be measured monthly thereafter .3. Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the Dietician in writing. Verbal notification must be confirmed in writing. 6. The threshold for significant unplanned and undesired weight loss will be based on the following criteria .b. 3 months - 7.5% weight loss is significant; greater than 7.5% is severe. C. 6 months - 10% weight loss is significant; greater than 10% is severe .Care Planning 1. Care planning for weight loss or impaired nutrition will be a multidisciplinary effort and will include the Physician, nursing staff, the Dietician, the Consultant Pharmacist, and the resident on resident's legal surrogate. 2. Individualized care plans shall address, to the extent possible: a. The identified cause of weight loss; b. Goals and benchmarks for improvement; and c. Time frames and parameters for monitoring and reassessment .
Review of the facility's Policy and Procedure titled Care Planning- Interdisciplinary Team revised September 2010 showed, an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident.3. Each resident's comprehensive care plan is designed to: a. Incorporate identified problem areas; b. Incorporate risk factors associated with identified problems; f. Identify the professional services that are responsible for each element of care; .4. Areas of concern that are triggered during the resident assessment are evaluated using specific assessment tools (including Care Area Assessments) .5.When possible, interventions address the underlying source(s) of the problem area (s) .9. The Care Planning/Interdisciplinary Team is responsible for the review and updating of care plans: a. When there has been a significant change in the resident's condition.
During a professional reference review of American Academy of Family Physicians Journal titled, Unintentional Weight Loss in Older Adults, dated 2014, the Journal indicated,
Unintentional weight loss (i.e., more than a 5% reduction in body weight within six to 12 months) occurs in 15% to 20% of older adults and is associated with increased morbidity and mortality.https://www.aafp.org/afp/2014/0501/p718.html - afp20140501p718-b1 In this population, unintentional weight loss can lead to functional decline in activities of daily living, increased in-hospital morbidity, increased risk of hip fracture in women, and increased overall mortality. Further, cachexia (loss of muscle mass with or without loss of fat) has been associated with negative effects such as increased infections, pressure ulcers, and failure to respond to medical treatments .
2. During a concurrent interview and record review, on 10/07/21 at 1:00 p.m., with LVN 1, Resident 114's PN was reviewed. The LVN 1 was unable to confirm documentation the RD was notified of the significant severe unplanned weight loss of 10.5 lbs., 8.6% in three months, from 5/15/21 through 8/16/21 and the significant severe unplanned weight loss of 12.5 lbs., 10.2% in five months, from 5/15/21 through 10/1/21 for Resident 114.
During a concurrent interview and record review on 10/7/21 at 3:07 p.m., with the Director of Nursing (DON), Resident 114's the WVS and the PN, dated 10/7/21 were reviewed. The DON stated, all newly admitted residents were weighed every week for four weeks and if stable, then weights were done monthly. The DON confirmed Resident 114 experienced a significant severe unplanned weight loss of 10.5 lbs., 8.6% in three months, from 5/15/21 through 8/16/21 and a significant unplanned weight loss of 12.5 lbs., 10.2% in five months, from 5/15/21 through 10/1/21. The DON stated, Resident 114's significant unplanned weight loss could result in anemia, electrolyte imbalance, dehydration, kidney failure, and further weight loss.
During a concurrent interview and record review on 10/7/21 at 3:15 p.m., with the Director of Nursing (DON), Resident 114's Dietician Nutritional Assessment (DNA), dated 5/13/21 was reviewed. The DON stated, the DNA for Resident 114 was completed by the Registered Dietician (RD) 2. Section B of the DNA indicated, Resident 114's caloric needs were between 1,230 and 1,420 calories. Section D of the DNA indicated, Resident 114's fluid needs were between 1,230 and 1,420 ml (unit of measurement). Section F of the DNA indicated the goal for Resident 114 was Resident will not have a significant weight change. Section G of the DNA indicated interventions for Resident 114's was diet is liberalized. Continue POC (Plan of Care). RD to monitor weights and follow up as needed. The DON was unable to validate a DNA addressing the significant severe unplanned weight loss of 10.5 lbs., 8.6% in three months, from 5/15/21 through 8/16/21, and the significant severe unplanned weight loss of 12.5 lbs., 10.2% in five months, from 5/15/21 through 10/1/21 was completed by the RD. The DON confirmed Resident 114 did not receive the appropriate follow-up assessment required by the RD according to the facility's policy.
During an interview on 10/8/21, at 3:48 p.m., with the RD 1, the RD 1 confirmed the significant severe unplanned weight loss of 8.6% within a three-month timeframe from 5/7/21 to 8/6/21 and the significant severe unplanned weight loss of 10.2 % within a five-month timeframe from 5/7/21 to 10/1/21 for Resident 114 were not addressed by the RD. RD 1 further stated the weight loss for Resident 114 was not acceptable.
A review of the facility's policy and procedure (P&P) titled, Weight Assessment and Intervention, dated September 2020, the P&P indicated, Weight Assessment .1. The nursing staff will measure resident weights on admission, the next day, and weekly for four weeks thereafter. If no weight concerns are noted at this point, weights will be measure monthly thereafter .3. Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the Dietician in writing. Verbal notification must be confirmed in writing. 6. The threshold for significant unplanned and undesired weight loss will be based on the following criteria .b. 3 months - 7.5% weight loss is significant; greater than 7.5% is severe. C. 6 months - 10% weight loss is significant; greater than 10% is severe .Care Planning 1. Care planning for weight loss or impaired nutrition will be a multidisciplinary effort and will include the Physician, nursing staff, the Dietician, the Consultant Pharmacist, and the resident on resident's legal surrogate. 2. Individualized care plans shall address, to the extent possible: a. The identified cause of weight loss; b. Goals and benchmarks for improvement; and c. Time frames and parameters for monitoring and reassessment .
During a professional reference review of American Academy of Family Physicians Journal titled, Unintentional Weight Loss in Older Adults, dated 2014, the journal indicated,
Unintentional weight loss (i.e., more than a 5% reduction in body weight within six to 12 months) occurs in 15% to 20% of older adults and is associated with increased morbidity and mortality.https://www.aafp.org/afp/2014/0501/p718.html - afp20140501p718-b1 In this population, unintentional weight loss can lead to functional decline in activities of daily living, increased in-hospital morbidity, increased risk of hip fracture in women, and increased overall mortality. Further, cachexia (loss of muscle mass with or without loss of fat) has been associated with negative effects such as increased infections, pressure ulcers, and failure to respond to medical treatments .