**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to manage and monitor the quality of care for one of 12 sampled residents (Resident 78), when the facility unjustly implemented a fluid restriction on Resident 78 without a clinical justification (diagnosis or medical need), comprehensive assessment or person-centered care plan. This failure had the potential for harm, including dehydration (occurs when your body loses more fluids than it takes in, leading to a lack of water and other vital fluids needed for normal bodily functions and could lead to a medical emergency) and electrolyte imbalance (having too much or too little of certain minerals (electrolytes) in your body, which can disrupt vital functions like muscle and nerve function, and fluid balance), for Resident 78 due to withholding fluid from him since admittance to the facility on 2/3/25. Findings: During a review of Resident 78's admission Record (a summary of important information regarding a patient which include patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 2/21/25, the admission Record indicated, Resident 78 was admitted to the facility on [DATE] with a diagnosis of cerebral infarction (a type of stroke that occurs when blood flow to the brain is blocked), history of endocarditis (a serious inflammation [the body's response to injury, infection, or irritation] of the heart's inner lining. It's usually caused by a bacterial infection [when tiny, harmful bacteria enter your body, multiply, and cause illness], but can also be caused by fungi[microorganisms (tiny living things (like bacteria, fungi, and some algae) that are too small to see with the naked eye and require a microscope to be observed) that can cause infections]), acute embolism (a sudden blockage in a blood vessel, often caused by a blood clot (or other substance) that travels from somewhere else in the body and gets lodged, potentially cutting off blood flow and oxygen to an organ or tissue) and thrombosis (the blockage of a blood vessel by a blood clot) and hypotension (low blood pressure). During a review of Resident 78's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive and physical function) assessment, dated 1/16/25, the MDS assessment indicated Resident 78's Brief Interview for Mental Status (BIMS -assessment of cognitive(define) status for memory and judgment) assessment score was 15 out of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 78 was cognitively intact. During a review of Resident 78's Order Audit Report (OAR), dated 2/20/25, the OAR indicated, .Order date: 2/3/25 at 12:08 p.m. Order Status: Active . Order Summary: Fluid restriction 1500 [milliliters (mL)- unit of measurement]/24 hours: Dietary 240 mL with breakfast, 240 mL with lunch, 240 mL with dinner. 260 mL each shift given by nursing staff . created by: Licensed Vocational Nurse [LVN] 2 . During a review of Resident 78's Care Plan, dated 2/4/25, the Care Plan indicated, .Description: The resident has fluid overload [a person has too much fluid, potentially causing swelling, shortness of breath, and high blood pressure] or potential fluid volume overload related to Kidney Failure [when the kidneys stop working properly, leading to a buildup of waste in your blood, which can be dangerous if left untreated] . Goal: The resident will comply with diet and/or fluid restrictions [a patient ordered to have a certain amount of liquid each day] daily through review date . During a review of Resident 78's admission History and Physical (H&P), dated 2/4/25, the H&P indicated, .Chief Complaint: Patient is admitted for rehab status post transfer [moving a patient from one place to another all while ensuring their medical care continues smoothly] from skilled nursing facility . status post transfer hospitalization for cerebrovascular accident [a medical emergency where blood flow to the brain is suddenly interrupted, either by a blockage or a rupture of a blood vessel, leading to potential brain damage] due to arterial septic emboli [infected blood clots that travel through the bloodstream and can block blood vessels, potentially causing damage to tissues or organs] . [AGE] year old male with past medical history significant for thrombophilia [a condition that makes your blood more likely to form clots] . osteomyelitis [a bone infection that causes inflammation and swelling], endocarditis and septic arterial embolism and generalized weakness is admitted for rehab . Physical Exam: . Blood pressure 109/61 . Pulse: 75 . Respirations: 16 . chest (lungs): clear breath sounds bilaterally [both sides] . Cardiovascular [heart]: . normal rate and rhythm . During a review of Resident 78's MDS Section I- Active Diagnosis (AD), dated 2/14/25, the AD indicated, .Primary Medical Condition: Cerebral Infarction . Heart/Circulation: Coronary artery disease [a heart condition that occurs when the coronary arteries narrow or become blocked]- No . Heart Failure [a chronic condition that occurs when the heart can't pump enough blood to meet the body's needs]- No . Peripheral vascular disease [a circulatory condition that occurs when blood vessels narrow, block, or spasm]- No . Genitourinary [urinary and genital organs]: Renal insufficiency [kidneys aren't working as well as they should, potentially leading to a buildup of waste and excess fluid in your body], renal failure [kidneys aren't working properly, leading to a buildup of waste and fluid in your body], End stage Renal Disease [kidneys aren't working properly, leading to a buildup of waste and fluid in your body]- No . Pulmonary [Lungs]: Asthma [a chronic lung disease that makes breathing difficult] or chronic lung disease [damage to the lungs or airway]- No . Respiratory Failure- No . During a review of Resident 78's Nursing Weekly Summary (NWS), dated 2/8/25, the NWS indicated, .Edema [swelling]: No . Respiratory Status: Breath sounds: Clear, Both .Shortness of breath: None . During a review of Resident 78's Lab Results Report (LRR), dated 1/2/25, the LRR indicated, .BUN [urea nitrogen a test that measures the amount of a waste product (urea nitrogen) in your blood which is formed when your body breaks down protein, and your kidneys filter it out]: 18 [milligrams per deciliter (mg/dl)- unit of measurement], Reference Range 7 - 25 mg/dl . Creatinine [a waste product in the blood that indicates how well your kidneys are working]: 0.69 mg/dl, Reference Range: .70 -1.30 mg/dl . [Estimated Glomerular Filtration Rate (eGFR) - a measure of how well your kidneys are filtering waste products from your blood] 96 [milliliters per minute ml/min] [greater than or equal to] 60 ml/min . Interpretation of eGFR: 60 or more mildly reduced (60 - 89) or Normal (90 or more) . [less than] 15 ml/min [means] Kidney Failure . During a review of Resident 78's Progress Note (PN), dated 2/21/25, the PN indicated, .Subjective: Evaluation for fluid restriction . Problem list: Cerebral infarction with right hemiparesis (right side of body weakness), thiamine deficiency [a person's body doesn't get enough thiamine, which is vital for converting food into energy and maintaining healthy nerves, muscles, and the heart], essential hypertension, acute thromboembolism [the blockage of a blood vessel by a blood clot ], endocarditis, heart valve disorder, chronic pain syndrome . Objective: he is in no acute distress. Vital signs: blood pressure 98/61 [millimeters of mercury (mmHg) -unit of measurement] . pulse [heartrate]: 79, respirations 18, saturation 90% on ambient air [room air] . There is no volume overload . Assessment: Cerebral infarction unspecified, thiamine deficiency, hyperlipidemia, essential hypertension, use of fluid restriction not clear . Plan and Management: . 2. Discontinue fluid restriction for one week. Repeat basic metabolic panel after one week . During a concurrent interview and record review on 2/20/25 at 10:19 a.m., with the Licensed Vocational Nurse (LVN) 1, Resident 78's Electronic Medical Record (EMR), dated 2/3/25 to 2/20/25 was reviewed. The EMR indicated Resident 78 had a care plan in place related to kidney failure, but no medical diagnosis or evidence in the record to support that. The LVN 1 stated he was the nurse responsible for Resident 78 today. LVN 1 stated there was no evidence of edema, fluid overload, nor kidney failure for Resident 78 in the EMR. LVN 1 stated there had not been any issues with Resident 78's physical exams since he had been at their facility. During an interview on 2/20/25 at 11:30 a.m., with the Registered Dietician (RD), the RD stated Resident 78 did not have any congestive heart failure (a serious condition that occurs when the heart can't pump enough blood to meet the body's needs) or kidney conditions as a diagnosis in the EMR. During an interview on 2/20/25 at 3:46 p.m., with the RD, the RD stated she looked at Resident 78's labs and did not see anything that would have warranted a fluid restriction or kidney failure referenced in the care plan. The RD stated Resident 78 was admitted with the fluid restriction order but could not find a medical reason for it. The RD stated she was not sure of the root cause for the fluid restriction that was ordered. During an interview on 2/20/25 at 4:24 p.m., with the Director of Nursing (DON), the DON stated Resident 78 did not have a diagnosis of a kidney problem. The DON stated a care plan should be based off of diagnosis and resident needs and Resident 78's care plan was not. The DON stated the facility was still in the process of investigating why Resident 78 was put on a fluid restriction at his previous facility. The DON stated the orders from the previous facility were kept at this facility and the fluid restriction was part of that. The DON stated Resident 78 had been on the fluid restriction since his admit to this facility on 2/3/25 but did not know who originally ordered the fluid restriction or why. During an interview on 2/21/25 at 9:59 a.m., with the Director of Staff Development (DSD- also the Infection Preventionist and LVN 2), the DSD stated she created the care plan for Resident 78. The DSD stated she was not sure the reason for the fluid restriction initially and was assuming to get the care plan completed. The DSD stated she put kidney failure without looking ahead and Resident 78 did not have evidence of kidney failure. The DSD stated the care plan was inaccurate in regard to fluid restriction and the kidney failure. The DSD stated care plans should be individualized and Resident 78's was not. The DSD stated the inaccuracy of the care plan would equate to care for Resident 78 not going to be correct. The DSD stated the policy and procedure (P&P) Care Planning was not followed. The DSD stated Resident 78 came with that fluid restriction order from another facility. The DSD stated the facility tried to obtain past medical records from previous hospital stays and doctor appointments to find the origin of the fluid restriction, but they did not currently have them. The DSD stated this was not good quality of care and Resident 78 could have potentially been dehydrated because of the order. During an interview on 2/21/25 at 2:09 p.m., with the DON, the DON stated care plans are for staff to provide continuity of care to the resident and the continuity of care was not there. The DON stated, she felt staff followed the P&P Care Planning. The DON stated, that was her opinion. The DON stated there were no assessments, nor objective evidence, in the EMR that indicated kidney failure. The DON stated the facility tried to be cautious with Resident 78 and that is why they kept the fluid restriction order from the previous facility. The DON stated after private review of the EMR, the fluid restriction was not a safe order for Resident 78 to be on and it was not justified. The DON stated there was not a current clinical indication, no physical exam or current diagnosis, on why Resident 78 should have had a fluid restriction order. The DON stated the fluid restriction was incorrect and a mistake. During an interview on 2/21/25 at 3 p.m., with Medical Doctor (MD) 1, MD 1 stated the Medical Director was on vacation and the facility called him to assess Resident 78. MD 1 stated he assessed Resident 78 today and completed a physical assessment which was normal. MD 1 stated Resident 78's lungs were not wet, not short of breath, no edema and nothing indicates a fluid restriction was needed. MD 1 stated Resident 78 did not have an active diagnosis of congestive heart failure or kidney issues and there were no problems in terms of fluid. MD 1 stated people make mistakes and we learn from them. During an interview on 2/21/25 at 4:57 p.m., with the DSD, the DSD stated there was no objective evidence, nor clinical reason, for Resident 78's fluid restriction. During an interview on 2/24/25 at 10:37 a.m., with LVN 1, LVN 1 stated care plans tell us how to care for the resident and keeps them stable. LVN 1 stated a potential outcome for having a care plan that was not based off of comprehensive assessment could have been a risk of injury due to inappropriate medical treatment. LVN 1 stated the P&P Care Planning was not followed by staff. LVN 1 stated Resident 78 did not have a comprehensive or current assessment that justified why he requireda fluid restriction order. LVN 1 stated potential outcomes would be Resident 78 not getting proper care and dehydration. LVN 1 stated Resident 78 was also denied the freedom of his choices due to not being able to drink however much he desired. LVN 1 stated there was no medical rationale, no congestive heart failure, end stage renal disease, nor acute kidney injury that would warrant the fluid restriction. During a review of the facility's P&P titled, Care Planning, dated 4/2024, the P&P indicated, .Policy: Care, treatment and services are planned to ensure they are appropriate to the resident needs . care planning will be implemented through the integration [the process of combining or uniting separate things into a whole] of assessment findings, consideration of the prescribed treatment plan and development of goals for the resident that are reasonable and measurable . the plan of care shall be individualized, based on diagnosis, resident assessment . care planning is based on data collected from resident assessments with integration of those assessment findings in the care planning process . During a review of National Institute of Health.gov Professional Reference title, Fluid Management, dated October 2023, found at (https://www.ncbi.nlm.nih.gov/books/NBK532305/#:~:text=Clinical%20Significance,help%20alleviate%20these%20potential%20problems.), the reference indicated, .Fluid management is crucial in inpatient medical settings, where each patient presents unique and individual requirements . Improper fluid management can cause significant morbidity [disease] and mortality [death] from volume [amount of fluid] depletion [lack of] or overload. Therefore, it is essential to carefully assess the specific type and quantity of fluids required for each patient . crucial role of the interprofessional healthcare team in managing patients' volume status, optimizing patient outcomes and reducing morbidity and mortality . Objectives: . Implement evidence-based fluid resuscitation and maintenance therapy guidelines for acute and critical care patients, considering their unique physiological needs . Identify potential risk factors and contraindications [a reason why a specific medical treatment or procedure shouldn't be used because it could be harmful to a person] related to fluid management in patients . Communicate effectively among the interprofessional healthcare team, including physicians, nurses, nutritionists, and pharmacists, to optimize fluid management strategies and improve patient outcomes . Treatment: . Assessment of vital signs, physical examinations, and supplementary laboratory data will help determine the appropriateness of each patient's fluid management strategy . During a review of Joint Commission.org Professional Reference title, Medication Order- Indication for Use Requirements, dated November 2021, (found at https://www.jointcommission.org/standards/standard-faqs/home-care/record-of-care-treatment-and-services-rc/000001696/), the reference indicated, .Does the medical record need to contain a diagnosis, condition, or indication for use for each medication ordered? . Yes. Standard MM.04.01.01 requires that there be documented indication for all medications ordered. That indication can be in the form of lab values, diagnoses, progress note entries, etc. In other words, the indication must be evident somewhere in the medical record. This requirement is found in the Medication Management chapter at MM.04.01.01. During a review of Nursing World.org Professional Reference titled, The American Nurses Association- Nursing: Scope and Standards of Practice, Third Edition, dated July 2015, (found at https://www.nursingworld.org/~4af71a/globalassets/catalog/book-toc/nssp3e-sample-chapter.pdf), the reference indicated, .The Standards of Practice describe a competent level of nursing care as demonstrated by the critical thinking model known as the nursing process. The nursing process includes the components of assessment, diagnosis, outcomes identification, planning, implementation, and evaluation. Accordingly, the nursing process encompasses significant actions taken by registered nurses and forms the foundation of the nurse's decision-making . Standard 1. Assessment The registered nurse collects pertinent data and information relative to the healthcare consumer's health or the situation . During a review of National Library of Medicine.org Professional Reference titled, Nursing Process, dated 4/10/23, (found at https://www.ncbi.nlm.nih.gov/books/NBK499937/), the reference indicated, . Planning: The planning stage is where goals and outcomes are formulated that directly impact patient care based on guidelines. These patient-specific goals and the attainment [the level of knowledge, skills, or qualifications a learner has acquired at a specific point in time] of such assist in ensuring a positive outcome. Nursing care plans are essential in this phase of goal setting. Care plans provide a course of direction for personalized care tailored to an individual's unique needs. Overall condition and comorbid conditions play a role in the construction of a care plan. Care plans enhance communication, documentation, reimbursement, and continuity of care across the healthcare continuum . vital to positive patient outcomes . the nursing process to guide care is clinically significant going forward in this dynamic, complex world of patient care. Aging populations carry with them a multitude of health problems and inherent risks of missed opportunities to spot a life-altering condition .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of one sampled residents (Resident 10) was free from accidents, when Resident 10 was smoking and had ashes fall on his shirt and into his wheelchair. This failure placed Resident 10's safety at risk and the ashes had the potential to burn the resident. Findings: During a review of Resident 10's admission Record (a summary of important information regarding a patient which include patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 2/21/25, the admission Record indicated, Resident 10 was admitted to the facility on [DATE] with a diagnosis of Dementia (a brain condition that causes memory loss, thinking problems, and behavioral changes), Cerebrovascular Accident (a medical emergency where the blood supply to the brain is suddenly interrupted, either by a blockage or a rupture of a blood vessel, leading to brain damage) and senile degeneration of brain (a decline in brain function, often associated with aging, that can lead to memory loss, difficulty with thinking and problem-solving, and changes in behavior). During a review of Resident 10's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive and physical function) assessment, dated 2/10/25, the MDS assessment indicated Resident 10's Brief Interview for Mental Status (BIMS -assessment of cognitive status for memory and judgment) assessment score was 5 out of 15 (a score of 13-15 indicates cognitively intact (a person is able to think clearly, remember things well, and make sound decisions, essentially having normal brain function with no significant problems with thinking, learning, or reasoning abilities), 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 10 was severely impaired. During a review of Resident 10's Smoking Order (SO), dated 2/26/24, the SO indicated . Order date: 2/26/24 at 9 a.m., Communication Method: Phone . Order Summary: Ok for resident to smoke nicotine products . at designated smoking area at designated smoking times . Confirmed by Licensed Vocational Nurse [LVN] 2 . During an observation on 2/19/25 at 11 a.m., in the designated smoking area on the back patio of the facility with Resident 10 and Activities Personnel (AP) 1, Resident 10 smoked three cigarettes and dropped ashes on his shirt and between his legs onto his wheelchair. Resident 10 was not wearing a smoking apron. During an interview on 2/20/25 at 11:06 a.m., with LVN 1, LVN 1 stated Resident 10 should have had a smoking apron (worn over the front of the body to prevent burns to clothing and keep hot ashes from burning the skin) on when he was smoking to prevent being burned. LVN 1 stated he needed the apron because he was not mentally alert and had poor safety awareness. LVN 1 stated due to Resident 10's BIMS, he could not keep himself safe. LVN 1 stated it was not safe for Resident 10 to be smoking if the ashes fell on him. During an interview on 2/21/25 at 9:59 a.m., with LVN 2 (she was also Director of Staff Development and Infection Preventionist), LVN 2 stated the expectation for Resident 10 was to be able to smoke safely. LVN 2 stated the expectation was not met and Resident 10 was at risk for burns and injury. LVN 2 stated the policy and procedure (P&P) Smoking Policy- Residents was not followed. During an interview on 2/21/25 at 3:13 p.m., with the Director of Nursing (DON), the DON stated Resident 10 should not have had ashes falling on him while smoking. The DON stated this was a safety concern. The DON stated the ashes could have still been hot and could have caused a skin injury. The DON stated the P&P Smoking Policy- Residents was not followed. During an interview on 2/24/25 at 10:51 a.m., with AP 1, AP 1 stated she was out there with Resident 10 and had not had any training in terms of facility smoking procedures. AP 1 stated her job was to take any resident out that was allowed to smoke and make sure they do not get burned. AP 1 stated she forgot to give Resident 10 a smoking apron that day. AP 1 stated Resident 10 dropping ashes on himself was a safety issue. AP 1 stated Resident 10 could catch fire and that was why the smoking apron should have been worn. During a review of the facility's P&P titled Smoking Policy- Residents, dated 5/2023, the P&P indicated, . this facility shall establish and maintain safe resident smoking practices . residents must be offered the non-combustible apron prior to smoking .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and record review, the facility failed to provide the correct diet for one of 12 sampled residents (Resident 2) during lunch tray assembly when Resident 2 was on a fortified diet (an enrichment of food to increase calories [a unit of energy] and protein [essential to building and repairing body tissues, muscles, and bones] to sustain or gain weight) and dietary staff did not follow the diet order on 2/18/25 to provide Resident 2 with a Magic Cup frozen dessert (ice cream with added calories and protein for those experiencing involuntary weight loss). This failure had the potential to result in Resident 2 to not receive the adequate nutritional requirements to sustain or gain weight. Findings: 1. During a record review of Resident 2's admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 2/24/25, the AR indicated, Resident 2 was admitted to the facility on [DATE], with diagnosis that included Hospice Care (palliative care for terminally ill residents), Confusional Arousals (a sleep disorder causing confusion and disorientation that occur during or shortly after waking from sleep), Dementia (a decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities), Hypertension (high blood pressure), Muscle Weakness, Repeated Falls, and Atrial Fibrillation (an irregular and often very rapid heart rate). During a record review of Resident 2's Physician Order Summary (POS), dated 2/24/25, the POS indicated, Resident 2 was on a Fortified Diet Mechanical Soft Texture (food that is chopped, grounded, or pureed to accommodate with swallowing), Thin Liquids Consistency. During a record review of the facility's [name of company] Weekly Menu February 2025 - Week 2 Fortified Lunch, dated 2/10/25-2/14/25, the guideline indicated, 4 ounce (oz- unit of measurement) Magic Cup. During a review of Resident 2's Minimum Data Set (MDS, an assessment tool which indicates physical, medical, and cognitive abilities), dated 2/18/25, the MDS indicated Resident 2's Brief Interview for Mental Status (BIMS) score was 3 out of 15 (0-7 indicated severe cognitive impairment [memory loss, poor decision making-skills], 8-12 moderate cognitive impairment, 13-15 cognitively intact). During a concurrent observation and interview on 2/18/25 at 12:10 p.m., with Resident 2 in the dining/activity room, Resident 2 was observed sitting in a chair, with an overbed table and meal tray for lunch. Resident 2's lunch tray consisted of one flour tortilla with ground meat and shredded cheese, pinto beans with shredded cheese, 8 ounce (equivalent to one cup) of 2 percent milk, a cup of coffee, a cup of green salad, and a slice of cake. Resident 2 was unable to give a meaningful response when asked about the palatability of her food. During a concurrent interview and record review on 2/19/25 at 1:53 p.m., with Dietary [NAME] (CK) 1, Resident 2's lunch tray photo, dated 2/18/25 was reviewed. CK 1 stated Resident 2's lunch tray was not served correctly, and the Magic Cup was missing. CK 1 stated Resident 2's Magic Cup was added to her meal tray to ensure resident received the needed extra calories for weight gain. CK 1 stated Resident 2 could potentially lose weight from not having appropriate diet served each meal. During a concurrent interview and record review on 2/19/25 at 3:13 p.m., with the Dietary Supervisor (DS), Resident 2's lunch tray photo, dated 2/18/25, was reviewed. The DS stated Resident 2's lunch tray was not prepared correctly, and the magic cup was missing. The DS stated she expected the dietary staff to check the diet order and meal tray during meal preparation and it was not done. The DS stated Resident 2 could possibly experience weight loss from not having proper diet served each meal. During a concurrent interview and record review on 2/20/25 at 9:42 a.m., with the Registered Dietician (RD), Resident 2's POS, undated, was reviewed. The RD stated Resident 2 had diet recommendations to be on a fortified diet while on Hospice. The RD stated dietary staff were expected to follow the recommended dietary order and it was not done. The RD stated Resident 2 could potentially lose weight from not having appropriate diet served each meal. During a review of the facility's Job Description titled, Dietary Cook/Worker, undated, the Job Description indicated, . Essential Job Functions: . Understand and follow color coding and abbreviations of tray cards and therapeutic (specialized meal plan designed to treat or manage specific health conditions) menus . Be familiar with policies and procedures of the dietary department . During a review of the facility's policy and procedure (P&P) titled, Diet Orders and Menu Distribution, dated 11/20, the P&P indicated, Policy: To device a systematic procedure to process diet orders and distribute menus . A. All information regarding diet orders is written on the diet communication sheet by the nursing staff . There must be a written diet order in the patient's medical record before food may be served to the patient .

Based on interview and record review, the facility failed to follow its Hospice (care that focuses on the quality of life for people who are experiencing an advanced, life-limiting illness) policy and procedures (P&P) for one of four sampled residents (Resident 10) when: 1. The pharmacy recommendation for Resident 10 to obtain Serum (blood test) B-12 (a vitamin essential for maintaining healthy red blood cells, nerves, and brain function), Creatinine Level (a blood test to check for the kidney's function), Liver Function (a blood test to check for liver's function) and BMP (Basic Metabolic Panel-measures various substances in the blood, including blood sugar and bone health) was not communicated to the Hospice provider. 2. The Hospice order for Resident 10 to discontinue all laboratory tests on 1/21/25 was not carried out and implemented. These failures had the potential to place Resident 10 at risk for receiving treatments or procedures against his wishes. Findings: 1. During a review of Resident 10's admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 2/21/25, the AR indicated, Resident 10 was admitted from an acute care hospital on 1/19/24 to the facility, with diagnoses that included Dementia (a decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities), Hypertension (high blood pressure), Cerebral Infarction (stroke- bleeding inside the brain), and Type 2 Diabetes Mellitus (high blood sugar). During a review of Resident 10's Physician Order Summary Report (POS), dated 2/21/25, the POS indicated, . admitted under the care of [Name of Hospice Agency] . Order Date 1/19/24 . Do Not Resuscitate [DNR-a legal document that instructs medical professionals not to perform resuscitation (artificial breathing) if a patient's breathing or heart stops] . During a concurrent interview and record review on 2/21/25 at 9:22 a.m., with the Director of Nursing (DON), Resident 10's Progress Note (PN), undated, and Pharmacy Monthly Medication Review Recommendation (MRR), dated 1/28/25 were reviewed. The MRR indicated, . patient is receiving [generic name](medication to control blood sugar level) 500 [milligram (mg) - unit of measurement] daily, which may deplete (reduce) vitamin B-12 and has the potential to cause lactic acidosis (excess amount of lactic acid in the blood, causing nausea, vomiting, exhaustion, fatigue and body aches). Please consider ordering a serum B-12 level as baseline and annually to monitor therapy, as well as serum creatinine level, liver function and BMP every 6 months . The DON stated she does not have any record the pharmacy recommendation was forwarded to the Hospice agency for review. During a phone interview and record review, on 2/21/25 at 1:54 p.m., with the Hospice Director of Patient Care Services (HDPCS), Resident 10's Hospice Clinical Record (HCR), dated 2/21/25 was reviewed. The DPCS stated Resident 10 was under Hospice care since 1/19/24 and they worked closely with the facility staff to meet Resident 10's physical, emotional, and spiritual needs. The DPCS stated they did not have any record of pharmacy recommendations to obtain various laboratory tests, otherwise they would act on it. During a concurrent interview and record review, on 2/21/25 at 5:05 p.m., with the DON, the facility's Hospice Program Policy and Procedure (P&P), dated 7/17 was reviewed. The P&P indicated, . 9. In general, it is the responsibility of the hospice to manage the resident's care as it relates to the terminal illness (a condition with no treatment) and related conditions . c. Providing medical direction, nursing, and clinical management of the terminal illness . 12. Our facility has designated [blank space] to coordinate care provided to the resident by our facility staff and the hospice staff . The DON stated she does not have any record or proof that the facility staff communicated the pharmacy recommendation to the hospice agency. The DON stated, If it's not documented, it didn't happen. During a concurrent interview and record review, on 2/24/25 at 11:29 a.m., with the Director of Staff Development (DSD, also the Infection Preventionist [IP] and Licensed Vocational Nurse [LVN] 2), Resident 10's Progress Note (PN), dated 2/24/25 and Physician Order Summary (POS), dated 2/24/25 were reviewed. The DSD stated she does not have any record the pharmacy recommendation was forwarded to the Hospice agency for review. The DSD stated Resident 10 could potentially receive treatment or procedures against his wishes. During a review of the facility's P&P titled, Hospice Program, dated 7/17, the P&P indicated, . Hospice services are available to residents at the end of life . 12. Our facility has designated [blank space] to coordinate care provided to the resident by our facility staff and the hospice staff .e. Ensuring that our facility staff provides orientation on the P&P of the facility, including resident rights, appropriate forms, and record keeping requirements, to hospice staff furnishing care to the residents . 13. Coordinated care plans for residents receiving hospice services . in order to maintain the resident's highest practicable physical, mental and psychosocial well-being . 2. During a concurrent interview and record review, on 2/21/25 at 1:57 p.m., with the Hospice Director of Patient Care Services (HDPCS), Resident 10's Hospice Physician Order (HPO), dated 1/21/25 was reviewed. The HPO indicated, . [discontinue] all routine labs [laboratory tests] . The HDPCS stated the expectation was for the facility staff to follow the hospice recommendation. During a concurrent interview and record review, on 2/21/25 at 5:05 p.m., with the DON, Resident 10's POS, undated 2/21/25, and Resident 10's HPO, dated 1/21/25 were reviewed. The DON stated she does not have any record or proof the facility staff received Resident 10's physician order to discontinue all laboratory tests from the hospice agency. The DON stated, If it's not documented, it didn't happen. During a concurrent interview and record review, on 2/24/25 at 11:31 a.m., with the DSD (also the IP and LVN 2), Resident 10's PN, dated 2/24/25, and Resident 10's POS, dated 2/24/25, were reviewed. The DSD stated she does not have any record the facility staff received a physician order to discontinue Resident 10's laboratory tests from the hospice agency. The DSD stated Resident 10's could potentially received treatment or procedures against his wishes. During a review of the facility's P&P titled, Hospice Program, dated 7/17, the P&P indicated, . Hospice services are available to residents at the end of life . 12. Our facility has designated [blank space] to coordinate care provided to the resident by our facility staff and the hospice staff .e. Ensuring that our facility staff provides orientation on the P&P of the facility, including resident rights, appropriate forms, and record keeping requirements, to hospice staff furnishing care to the residents . 13. Coordinated care plans for residents receiving hospice services . in order to maintain the resident's highest practicable physical, mental and psychosocial well-being .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement comprehensive person-centered care plans (CP - a detailed approach to care customized to an individual resident's needs) for two of 12 sampled residents (Resident 12 and Resident 78 ) when: 1. There was no CP created addressing Resident 12's diagnosis of Chronic Obstructive Pulmonary Disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe.) 2. Resident 78 had a care plan for fluid overload (a person has too much fluid, potentially causing swelling, shortness of breath, and high blood pressure) related to kidney failure (when the kidneys stop working properly, leading to a buildup of waste in your blood, which can be dangerous if left untreated), but there was not a comprehensive assessment that reflected the medical issue. These failures had the potential to prevent Resident 12 and Resident 78 from receiving appropriate, and individualized care and services consistent with their needs. Findings: 1. During a review of Resident 12's admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 11/28/23, the AR indicated, Resident 12 was admitted from the acute care hospital on 9/27/24 to the facility, with diagnoses that included COPD, Muscle Weakness, Hypertension (high blood pressure), Cerebral Infarction (stroke- loss of blood flow to part of the brain), and Schizophrenia (chronic and severe mental disorder that affects the way a person thinks, acts, expresses emotions, perceives reality, and relates to others). During a review of Resident 12's Minimum Data Set (MDS, an assessment tool which indicates physical, medical, and cognitive abilities), dated 1/10/25, the MDS indicated Resident 12's Brief Interview for Mental Status (BIMS) 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). During a concurrent observation and interview on 2/19/25 at 10:50 a.m., with Resident 12 inside his room, Resident 12 was observed lying in bed, covered with a light white sheet and head of bed was elevated about 30 degrees. Resident 12 stated he has a diagnosis of COPD and takes routine and as needed medication (PRN) to improve his breathing. Resident 12 stated he uses an inhaler whenever he experienced sudden shortness of breath. During a concurrent interview and record review on 2/19/25 at 3:30 p.m. with Licensed Vocational Nurse (LVN) 1, Resident 12's Physician Order Summary (POS), and Care Plan (CP), undated, were reviewed. The POS indicated, . Fluticasone Furoate-Vilanterol [medication used to control wheezing (high pitch whistling sound), shortness of breath (SOB), and chest tightness] 100-25 [MCG (microgram-unit of measurement) /ACT (actuation-the action of causing a machine or device to operation] () one puff inhale orally one time a day for COPD . Order Date 9/30/24 . Albuterol Sulfate Inhalation [medication used to treat breathing problems related to COPD and other respiratory issues] 108 MCG/ACT 2 puff inhale orally every six hours as needed for SOB or wheezing . LVN 1 stated there was no care plan developed and implemented for Resident 12's diagnosis of COPD. LVN 1 stated licensed nurses should care plan the COPD diagnosis so all nursing staff (caring for the resident) would know the plan of care for the resident and to ensure Resident 12 received the appropriate interventions. LVN 1 stated, the facility failed to follow the facility's policy and procedure (P&P) related to care planning process. During a concurrent interview and record review on 2/20/25 at 10:32 a.m., with the Director of Nursing (DON), Resident 12's POS and CP, undated, were reviewed. The DON stated a resident specific care plan should have been developed to address Resident 12's diagnosis of COPD and it was not done. The DON stated the CP was a form of communication with other team members, without a resident specific CP, the staff do not have a clear path to meet Resident 12's medical, physical, mental, and psychosocial needs. The DON stated the failure could potentially result in Resident 12's COPD to worsen. During a review of the facility's policy and procedure (P&P) titled, Care Planning, dated 4/24, the P&P indicated, . Care, treatment and services are planned to ensure they are appropriate to the resident's needs . Within seven (7) days of completion of the comprehensive assessments, all residents shall have a computerized plan of care generated by the Registered Nurse or the Licensed Practical/Vocational Nurse . The plan of care shall be individualized, based on the diagnosis, resident assessment and personal goals of the resident and his/her family . During a review of the facility's document titled, Job Description: Licensed Vocational Nurse, undated, the document indicated, . Essential Job Functions include, but are not limited to the following . Assessment of Residents . Following all facilities Policies and Procedures . Perform other duties as requested . 2. During a review of Resident 78's admission Record, dated 2/21/25, the admission Record indicated, Resident 78 was admitted to the facility on [DATE] with a diagnosis of cerebral infarction (a type of stroke that occurs when blood flow to the brain is blocked), history of endocarditis (a serious inflammation of the heart's inner lining. It's usually caused by a bacterial infection [when tiny, harmful bacteria enter your body, multiply, and cause illness], but can also be caused by fungi [microorganisms that can cause infections]), acute embolism a sudden blockage in a blood vessel, often caused by a blood clot (or other substance) that travels from somewhere else in the body and gets lodged, potentially cutting off blood flow and oxygen to an organ or tissue) and thrombosis (the blockage of a blood vessel by a blood clot) and hypotension (low blood pressure). During a review of Resident 78's MDS assessment, dated 1/16/25, the MDS assessment indicated Resident 78's Brief Interview for Mental Status (BIMS -assessment of cognitive(define) status for memory and judgment) assessment score was 15 out of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 78 was cognitively intact. During a review of Resident 78's Care Plan, dated 2/4/25, the Care Plan indicated, .Description: The resident has fluid overload or potential fluid volume overload related to Kidney Failure [when the kidneys stop working properly, leading to a buildup of waste in your blood, which can be dangerous if left untreated] . Goal: The resident will comply with diet and/or fluid restrictions [a patient can only have a certain amount of liquid each day] daily through review date . During a review of Resident 78's admission History and Physical (H&P), dated 2/4/25, the H&P indicated, .Chief Complaint: Patient is admitted for rehab status post transfer (moving a patient from one place to another all while ensuring their medical care continues smoothly) from skilled nursing facility . status post transfer hospitalization for cerebrovascular accident due to arterial septic emboli [infected blood clots that travel through the bloodstream and can block blood vessels, potentially causing damage to tissues or organs] . [AGE] year old male with past medical history significant for thrombophilia [a condition that makes your blood more likely to form clots] . osteomyelitis [a bone infection that causes inflammation and swelling], endocarditis and septic arterial embolism and generalized weakness is admitted for rehab . Physical Exam: . Blood pressure 109/61 . Pulse: 75 . Respirations: 16 . chest (lungs): clear breath sounds bilaterally (both sides) . Cardiovascular (heart): . normal rate and rhythm . During a review of Resident 78's MDS Section I- Active Diagnosis (AD), dated 2/14/25, the AD indicated, .Primary Medical Condition: Cerebral Infarction . Heart/Circulation: Coronary artery disease [a heart condition that occurs when the coronary arteries narrow or become blocked]- No . Heart Failure [a chronic condition that occurs when the heart can't pump enough blood to meet the body's needs]- No . Peripheral vascular disease [a circulatory condition that occurs when blood vessels narrow, block, or spasm]- No . Genitourinary [urinary and genital organs]: Renal insufficiency [kidneys aren't working as well as they should, potentially leading to a buildup of waste and excess fluid in your body], renal failure [kidneys aren't working properly, leading to a buildup of waste and fluid in your body], End stage Renal Disease [kidneys aren't working properly, leading to a buildup of waste and fluid in your body]- No . Pulmonary [Lungs]: Asthma or chronic lung disease- No . Respiratory Failure- No . During a review of Resident 78's Nursing Weekly Summary (NWS), dated 2/8/25, the NWS indicated, .Edema (swelling): No . Respiratory Status: Breath sounds: Clear, Both .Shortness of breath: None . During a review of Resident 78's Lab Results Report (LRR), dated 1/2/25, the LRR indicated, .BUN [urea nitrogen a test that measures the amount of a waste product (urea nitrogen) in your blood which is formed when your body breaks down protein, and your kidneys filter it out]: 18 [milligrams per deciliter- unit of measurement], Reference Range 7 - 25 mg/dl . Creatinine [a waste product in the blood that indicates how well your kidneys are working]: 0.69 mg/dl, Reference Range: .70 -1.30 mg/dl . eGFR [Estimated Glomerular Filtration Rate. It is a measure of how well your kidneys are filtering waste products from your blood] 96 ml/min (milliliters per minute) >= [greater than or equal too] 60 ml/min . Interpretation of eGFR: 60 or more mildly reduced (60 - 89) or Normal (90 or more) . [less than] 15 ml/min [means] Kidney Failure . During a concurrent interview and record review on 2/20/25 at 10:19 a.m., with the Licensed Vocational Nurse (LVN) 1, Resident 78's Electronic Medical Record (EMR) dated 2/3/25 to 2/20/25 was reviewed. The EMR indicated Resident 78 had a care plan in place related to kidney failure, but no medical diagnosis or evidence in the record to support that. The LVN 1 stated there was no evidence of edema, fluid overload, nor kidney failure for Resident 78 in the EMR. During an interview on 2/20/25 at 11:30 a.m., with the Registered Dietician (RD), the RD stated Resident 78 did not have any kidney conditions as a diagnosis. During an interview on 2/20/25 at 3:46 p.m., with the RD, the RD stated she looked at Resident 78's labs and did not see anything that would have warranted a fluid restriction or kidney failure. The RD stated she was not sure of the root cause for the fluid restriction that was mentioned in the care plan. During an interview on 2/20/25 at 4:24 p.m., with the DON, the DON stated Resident 78 did not have a diagnosis of a kidney problem. The DON stated a care plan should be based off of diagnosis and resident needs and Resident 78's care plan was not. During an interview on 2/21/25 at 9:59 a.m., with the Director of Staff Development (DSD- also the Infection Preventionist and LVN 2), the DSD stated she created the care plan for Resident 78. The DSD stated she was not sure the reason for the fluid restriction initially and was assuming to get the care plan completed. The DSD stated she put kidney failure without looking ahead and Resident 78 did not have evidence of kidney failure. The DSD stated the care plan was inaccurate in regard to fluid restriction and the kidney failure. The DSD stated care plans should be individualized and Resident 78's was not. The DSD stated the inaccuracy of the care plan would equate to care for Resident 78 not going to be correct. The DSD stated the policy and procedure (P&P) Care Planning was not followed. During an interview on 2/21/25 at 2:09 p.m., with the DON, the DON stated care plans are for staff to provide continuity of care to the resident and the continuity of care was not there. The DON stated, she felt staff followed the P&P Care Planning. The DON stated, that was her opinion. The DON stated there were no assessments, nor objective evidence, in the EMR that indicated kidney failure. During an interview on 2/24/25 at 10:37 a.m., with LVN 1, LVN 1 stated care plans tell us how to care for the resident and keeps them stable. LVN 1 stated a potential outcome for having a care plan that was not based off of comprehensive assessment could have been a risk of injury due to inappropriate medical treatment. LVN 1 stated the P&P Care Planning was not followed by staff. During a review of the facility's P&P titled, Care Planning, dated 4/2024, the P&P indicated, .Policy: Care, treatment and services are planned to ensure they are appropriate to the resident needs . care planning will be implemented through the integration of assessment findings, consideration of the prescribed treatment plan and development of goals for the resident that are reasonable and measurable . the plan of care shall be individualized, based on diagnosis, resident assessment . care planning is based on data collected from resident assessments with integration of those assessment findings in the care planning process . During a review of Nursing World.org Professional Reference titled, The American Nurses Association- Nursing: Scope and Standards of Practice, Third Edition, dated July 2015, (found at https://www.nursingworld.org/~4af71a/globalassets/catalog/book-toc/nssp3e-sample-chapter.pdf) the reference indicated, .The Standards of Practice describe a competent level of nursing care as demonstrated by the critical thinking model known as the nursing process. The nursing process includes the components of assessment, diagnosis, outcomes identification, planning, implementation, and evaluation. Accordingly, the nursing process encompasses significant actions taken by registered nurses and forms the foundation of the nurse's decision-making . Standard 1. Assessment The registered nurse collects pertinent data and information relative to the healthcare consumer's health or the situation . During a review of National Library of Medicine.org Professional Reference titled, Nursing Process, dated 4/10/23, (found at https://www.ncbi.nlm.nih.gov/books/NBK499937/) the reference indicated, . Planning: The planning stage is where goals and outcomes are formulated that directly impact patient care based on guidelines. These patient-specific goals and the attainment [the level of knowledge, skills, or qualifications a learner has acquired at a specific point in time] of such assist in ensuring a positive outcome. Nursing care plans are essential in this phase of goal setting. Care plans provide a course of direction for personalized care tailored to an individual's unique needs. Overall condition and comorbid conditions play a role in the construction of a care plan. Care plans enhance communication, documentation, reimbursement, and continuity of care across the healthcare continuum . vital to positive patient outcomes . the nursing process to guide care is clinically significant going forward in this dynamic, complex world of patient care. Aging populations carry with them a multitude of health problems and inherent risks of missed opportunities to spot a life-altering condition .

Based on interview and record review, the facility failed to ensure services provided met professional standards of quality for two of 12 sampled residents (Resident 10 and Resident 22) when: 1. Resident 10's pharmacy recommendation to obtain Serum (blood test) B-12 (a vitamin essential for maintaining healthy red blood cells, nerves, and brain function), Creatinine Level (a blood test to check for the kidney's function), Liver Function (a blood test to check for liver's function) and BMP (Basic Metabolic Panel-measures various substances in the blood, including blood sugar and bone health) was not communicated to the Hospice provider. This failure had the potential to place Resident 10 at risk of receiving treatment or procedures against his wishes. 2. Resident 22's pharmacy recommendation to rinse mouth with water and spit back into cup after use of Budesonide-Formoterol Fumarate Dihydrate inhaler (medication used to control shortness of breath (SOB) and chest tightness) was not implemented. This failure had the potential to place Resident 22 at risk of developing oral thrush (a type of mouth infection). Findings: 1. During a review of Resident 10's admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 2/21/25, the AR indicated, Resident 10 was admitted from an acute care hospital on 1/19/24 to the facility, with diagnoses that included Dementia (a decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities), Hypertension (high blood pressure), Cerebral Infarction (stroke- bleeding inside the brain), and Type 2 Diabetes Mellitus (high blood sugar). During a review of Resident 10's Physician Order Summary Report (POS), dated 2/21/25, the POS indicated, . admitted under the care of [Name of Hospice Agency] . Order Date 1/19/24 . Do Not Resuscitate [DNR-a legal document that instructs medical professionals not to perform resuscitation (artificial breathing) if a patient's breathing or heart stops] . During a concurrent interview and record review on 2/21/25 at 9:22 a.m., with the Director of Nursing (DON), Resident 10's Progress Note (PN), undated, and Resident 10's Pharmacy Monthly Medication Review Recommendation (MRR), dated 1/28/25 were reviewed. The MRR indicated, . patient is receiving Metformin (medication to control blood sugar level) 500 [milligram (mg) - unit of measurement] daily, which may deplete (reduce) vitamin B-12 and has the potential to cause lactic acidosis (excess amount of lactic acid in the blood, causing nausea, vomiting, exhaustion, fatigue and body aches). Please consider ordering a serum B-12 level as baseline and annually to monitor therapy, as well as serum creatinine level, liver function and BMP every 6 months . The DON stated she does not have any record the pharmacy recommendation was forwarded to the Hospice agency for review. During a phone interview and record review, on 2/21/25 at 1:54 p.m., with the Hospice Director of Patient Care Services (HDPCS), Resident 10's Hospice Clinical Record (HCR), dated 2/21/25 was reviewed. The DPCS stated Resident 10 was under Hospice care since 1/19/24 and they worked closely with the facility staff to meet Resident 10's physical, emotional, and spiritual needs. The DPCS stated they did not have any record of pharmacy recommendations to obtain various laboratory tests, otherwise they would act on it. During a concurrent interview and record review, on 2/21/25 at 5:05 p.m., with the DON, the facility's Hospice Program Policy and Procedure (P&P), dated 7/17 was reviewed. The P&P indicated, . 9. In general, it is the responsibility of the hospice to manage the resident's care as it relates to the terminal illness [a condition with no treatment] and related conditions . c. Providing medical direction, nursing, and clinical management of the terminal illness . 12. Our facility has designated [blank space] to coordinate care provided to the resident by our facility staff and the hospice staff . The DON stated she does not have any record or proof that the facility staff communicated the pharmacy recommendation to the hospice agency. The DON stated, If it's not documented, it didn't happen. During a concurrent interview and record review, on 2/24/25 at 11:29 a.m., with the Director of Staff Development (DSD, also the Infection Preventionist [IP] and Licensed Vocational Nurse [LVN] 2), Resident 10's Progress Note (PN), dated 2/24/25 and Physician Order Summary (POS), dated 2/24/25 were reviewed. The DSD stated she does not have any record the pharmacy recommendation was forwarded to the Hospice agency for review. The DSD stated Resident 10 could potentially receive treatment or procedures against his wishes. During a review of the facility's P&P titled, Charting and Documentation, dated 7/17, 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, 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 . 7. Documentation of procedures and treatments will include care-specific details, including . date and time of the procedure/treatment was provided . name and title of individual(s) who provided the care . During a review of the facility's document titled, Job Description: Charge Nurse Licensed Vocational Nurse (LVN), dated 8/2015, the document indicated, . Deliver and maintain optimum resident care and comfort by demonstrating knowledge and skills of current nursing practices . 2. During a review of Resident 22's AR, dated 2/21/25, the AR indicated, Resident 22 was admitted from an acute care hospital on 6/1/23 to the facility, with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD-is a chronic inflammatory lung disease that causes obstructed airflow of the lungs), Hypertension (high blood pressure), and Respiratory Failure (a serious condition that makes it difficult to breathe). During a review of Resident 22's POS, dated 2/21/25, the POS indicated, . Budesonide-Formoterol Fumarate Dihydrate [medication used to control shortness of breath (SOB) and chest tightness] 160-4.5 MCG (microgram-unit of measurement) /ACT (actuation-the action of causing a machine or device to operation] one puff inhale orally two times a day for COPD . Order Date 6/1/24 . During a concurrent interview and record review, on 2/21/25 at 9:26 a.m., with the Director of Nursing (DON), Resident 22's Medication Administration Record (MAR), dated 2/21/25 and MRR, dated 1/28/25 were reviewed. The MRR indicated, . This Resident is receiving Budesonide-Formoterol Fumarate Dihydrate. Steroid inhalers can cause oral thrush which may be minimized by rinsing the mouth with water after each dose of the inhaler. Please consider adding the following verbiage to the order as a reminder: Rinse mouth with water and spit back into cup after use . The DON stated she does not have any record the pharmacy recommendation was noted and acted upon by the facility. The DON stated, If it's not documented, it didn't happen. The DON stated Resident 22 could potentially develop oral thrush from using the inhaler and not rinsing her mouth with water after medication administration. During a concurrent interview and record review, on 2/24/25 at 11:34 a.m., with the Infection Preventionist (IP, also the Director of Staff Development [DSD] and Licensed Vocational Nurse [LVN] 2), Resident 22's MRR, dated 1/28/25 and MAR, dated 2/24/25 were reviewed. The DSD stated she does not have any record the pharmacy recommendation was acknowledged and acted upon by the facility. The DSD stated Resident 22 could potentially develop oral infection from using oral inhalers. During a review of the facility's P&P titled, Medication Regimen Review and Reporting, dated 1/07, the P&P indicated, . Medication Regimen Review (MRR) or Drug Regimen Review is a thorough evaluation of the medication regimen of a resident, with a goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication . During a review of the facility's P&P titled, Charting and Documentation, dated 7/17, 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, 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 . 7. Documentation of procedures and treatments will include care-specific details, including . date and time of the procedure/treatment was provided . name and title of individual(s) who provided the care . During a review of the facility's document titled, Job Description: Charge Nurse Licensed Vocational Nurse (LVN), dated 8/2015, the document indicated, . Deliver and maintain optimum resident care and comfort by demonstrating knowledge and skills of current nursing practices .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure effective infection prevention and control practices were implemented for nine of 14 sampled residents (Resident 21, 11, 5, 16, 15, 78, 8, 14, and 20) when: 1. Licensed Vocational Nurse (LVN) 1 did not perform hand hygiene when entering and exiting the rooms for Resident 21, 11, 5, 16, 15, 78, 8, 14, and 20. 2. LVN 1 did not remove gloves after providing patient care for Resident 16, 78, 14, and 20 and exited the room and walked down the hallway back to his medication cart (a mobile cart for storing and delivering medications). 3. LVN 1 did not take his medication cart located in Nursing Station 1 instead of bringing it to each room while administering medications and patient care for Resident 21, 11, 5, 16, 15, 78, 8, 14, and 20. These failures had the potential to result in the spread of infections (when germs enter the body and cause illness) and cross-contamination (transfer of germs or substances from one surface to another), compromising the health and safety of the residents. Findings: 1. During a review of Resident 21's admission Record (AR), dated 2/29/25, the AR indicated Resident 21 was admitted on [DATE] with a diagnosis(es) of vascular dementia (memory loss caused by poor blood flow to the brain), cerebral edema (swelling in the brain), Type 2 diabetes mellitus (a disease that causes high levels of sugar in the blood) and essential hypertension (high blood pressure with no clear cause). During a review of Resident 11's AR, dated 2/19/25, the AR indicated, Resident 11 was admitted on [DATE] with a diagnosis(es) of diabetes mellitus, essential hypertension, dehydration (when the body loses too much water), and constipation (hard stools) During a review of Resident 5's AR, dated 2/19/25, the AR indicated, Resident 5 was admitted on [DATE] with a diagnosis(es) of muscle weakness, pain unspecified (pain without clear cause or location), difficulty walking, and pain in the right and left knee. During a review of Resident 16's AR, dated 2/19/25, the AR indicated, Resident 16 was admitted on [DATE] with a diagnosis(es) of Type 2 diabetes mellitus and gastro-esophageal reflux disease without esophagitis (a condition where stomach acid leaks into the throat without causing inflammation). During a review of Resident 15's AR, dated 2/19/25, the AR indicated, Resident 15 was admitted on [DATE] with a diagnosis(es) of unspecified atrial fibrillation (an irregular and fast heart beat) essential hypertension, hyperlipidemia (high levels of fat in the blood), hypothyroidism (a condition when the thyroid [a small gland in the neck] makes too little hormones [a chemical that help control body functions]), anemia (not enough red blood cells to carry oxygen), and muscle weakness. During a review of Resident 78's AR, dated 2/19/25, the AR indicated, Resident 78 was admitted on [DATE] with a diagnosis(es) of essential hypertension, chest pain, and presence of cardiac pacemaker (a device that helps regulate a heart's rhythm). During a review of Resident 8's AR, dated 2/19/25, the AR indicated, Resident 8 was admitted on [DATE] with a diagnosis(es) of chronic obstructive pulmonary disease (a lung disease that makes it hard to breath), allergic contact dermatitis (a skin rash caused by an allergic reaction to something that touches the skin), unspecified dementia (a decline in memory and thinking skills without a clear cause) and essential hypertension. During a review of Resident 14's AR, dated 2/19/25, the AR indicated, Resident 14 was admitted on [DATE] with a diagnosis(es) of type 2 diabetes mellitus, klebsiella pneumoniae (a bacteria [germ] that can cause lung infections and other diseases), and urinary tract infection (an infection in the urinary tract). During a review of Resident 20's AR, dated 2/19/25, the AR indicated, Resident 20 was admitted on [DATE] with a diagnosis(es) of type 2 diabetes mellitus. During an observation on 2/19/25 at 8:31 a.m. in Resident 21's room, LVN 1 took Resident 21's blood pressure (the force of blood against the veins [blood vessels that carry blood to the heart] and arteries [blood vessels that carry blood away from the heart] as the heart pumps) using a blood pressure machine (a machine used to measure blood pressure). LVN 1 exited the room and did not perform hand hygiene (cleaning hands to remove germs and prevent infections). During an observation on 02/19/25 at 8:43 a.m., LVN 1 did not perform hand hygiene when he entered Resident 11's room. LVN 1 administered loperamide (a medication to control symptoms of diarrhea) 2mg (milligrams-a unit of measure) to Resident 11 and did not perform hand hygiene before exiting Resident 11's room. During an observation on 2/19/25 at 8:49 a.m., LVN 1 did not perform hand hygiene when he entered Resident 5's room. LVN 1 administered a lidocaine patch (a medicated patch that numbs pain in a specific area) 5% (percent- a unit of measure) to Resident 5's right knee and did not perform hand hygiene when he exited Resident 5's room. During an observation on 2/19/25 at 8:53 a.m., LVN 1 administered lorazepam (a medication used to control anxiety [feeling of worry, fear or nervousness]) 0.5ml (milliliter-a unit of measure) to Resident 16. LVN 1 did not perform hand hygiene when he exited Resident 16's room. During an observation on 2/19/25 at 11:08 a.m. in Resident 15's room, LVN 1 did not perform hand hygiene after he administered medications to Resident 15 and exited the Resident 15's room. During an observation on 2/19/25 at 11:11 a.m., LVN 1 went inside Resident 78's room to check his blood pressure. LVN 1 did not do hand hygiene when he entered Resident 78's room. LVN 1 had a gloved hand when he exited Resident 78's room and did not perform hand hygiene when he exited. During an observation on 2/19/25 at 11:16 a.m. in Resident 8's room, LVN 1 wore gloves and administered Resident 8's polyethylene glycol (a medication used to relieve dry, irritated eyes) 400 0.4%, propylene glycol 0.3% . LVN 1 removed his gloves and did not perform hand hygiene when he exited the room. During an observation on 2/19/25 at 11:24 a.m. in Resident 14, LVN 1 checked Resident 14's blood sugar using a glucometer (a devise that measures blood sugar). LVN 1 walked out of the room and did not perform hand hygiene. During an observation on 2/19/25 at 11:28 a.m. in Resident 14's room, LVN 1 administered insulin on Resident 14's lower left abdomen. LVN 1 removed his gloves after he administered the insulin (a medication that controls blood sugar) and did not perform hand hygiene. During an observation on 2/19/25 11:41 a.m. in Resident 20's room, LVN 1 entered Resident 20's room and did not perform hand hygiene. LVN 1 donned (put on) gloves and administered insulin on Resident 20's lower right abdomen. LVN 1 removed his gloves and did not perform hand hygiene and went back to the medication cart in Nursing Station 1. During an interview on 2/19/25 at 12:08 p.m. with LVN 1, LVN 1 stated, he should have performed hand hygiene before and after leaving a resident's room and before and after performing patient care. LVN 1 stated, after performing patient care for three to four residents, he should have washed his hands with soap and water. LVN 1 stated, it was important to perform hand hygiene to prevent cross-contamination from one patient to another and prevent the spread of infections. During an interview on 2/19/25 at 2:01 p.m. with the Infection Preventionist (IP), the IP stated, it was her expectation to perform hand hygiene whenever a staff entered and exited a resident's room. The IP stated, hand hygiene should also have been performed before and after performing patient care such as checking blood sugars, checking blood pressures, and administering medications. The IP stated, it was important to perform hand hygiene to prevent the spread of infections and prevent cross-contaminations. During an interview on 2/21/25 at 11:34 a.m. with the Director of Nursing (DON), the DON stated, staff had to perform hand hygiene before and after entering a resident's room and before and after providing patient care. The DON stated, failure to adhere to hand hygiene protocols could have led to cross-contamination and the spread of infection. During a review of the facility's policy and procedure (P&P) titled, Handwashing/Hand Hygiene, dated 8/2019, the P&P indicated, .all personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors .hand hygiene products and supplies (sinks, soaps, towels, alcohol-based hand rubs, etc.) shall be readily accessible and convenient for staff to encourage compliance with hand hygiene policies . use some alcohol based hand rope containing at least 62% alcohol; Or, alternatively, soap (antimicrobial [a substance that kills or stops germs]) . before and after direct contact with residents . Before preparing or handling medications . before performing any non-surgical invasive (enot breaking the skin or entering the body) procedures . Before and after handling an invasive device (e.g. Urinary catheters, IV access sites) . before donning sterile gloves . after contact with the resident's intact skin . after contact with blood or bodily fluids . after handling used dressings, contaminated (dirty or exposed to germs) equipment . after contact with objects (e.g., medical equipment) . after removing gloves . hand hygiene is the final step after removing and disposing of personal protective equipment . the use of gloves does not replace hand washing/hand hygiene . 2. During an observation 2/19/25 at 8:53 a.m., LVN 1 wore a glove when he administered Resident 16's lorazepam. LVN 1 left the room while wearing the same glove back to the medication cart in Nursing Station 1. During an observation on 2/19/25 at 11:11 a.m., LVN 1 wore gloves when he took Resident 78's blood pressure. LVN 1 left the room while wearing the same glove back to the medication cart in Nursing Station 1. During an observation on 2/19/25 at 11:24 a.m., in Resident 14's room, LVN 1 wore gloves while checking Resident 14's blood sugar using a glucometer. LVN 1 did not remove his gloves after checking Resident 14's blood sugar and left the room. LVN 1 walked from Resident 14's room to the medication cart in Nursing Station 1 while still wearing his gloves. During an observation on 2/19/25 at 11:35 a.m., LVN 1 wore gloves while checking Resident 20's blood sugar using a glucometer. LVN 1 did not remove his gloves after checking Resident 20's blood sugar and left the room. LVN 1 walked from Resident 20's room to the medication cart in Nursing Station 1 while still wearing his gloves. During an interview on 2/19/25 at 12:08 p.m. with LVN 1, LVN 1 stated he should not have worn gloves in the hallway after finishing patient care. LVN 1 stated, there was a risk of cross-contamination when walking in the hallway. LVN 1 stated, he could have been distracted and touched something in the hallway that could have harbored germs and potentially spread them to other residents. During an interview on 2/19/25 at 2:01 p.m. with the IP, the IP stated, gloves should not have been worn while walking in the hallway. The IP stated, there was potential for cross-contamination when soiled gloves were worn in the hallway and could have potentially caused infections to spread. The IP stated, gloves should be removed before exiting a resident's room. During an interview on 2/2/25 at 11:34 a.m. with the DON, the DON stated, nurses should not walk down the hallway with gloved hands after providing patient care. The DON stated, walking with soiled gloves could potentially cause cross-contamination and spread infections. During a review of the facility's P&P titled, Handwashing/Hand Hygiene, dated 8/2019, the P&P indicated, .The use of gloves does not replace hand/hygiene .integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections .applying and removing gloves .perform hand hygiene before applying non-sterile gloves . During a review of the professional reference (PR) titled, CDC's Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings found on www.cdc.gov/infection-control/hcp/core-practices/index.html, dated 4/12/24, the PR indicated, .remove and discard PPE, other than respirators, upon completing a task before leaving the patient's room or care area .remove and discard disposable gloves upon completion of a task or when soiled during the process of care . 3. During a concurrent observation and interview on 2/19/25 at 8:40 a.m. with LVN 1 in Resident 21's room, LVN 1 administered Resident 21's morning medications. LVN 1 prepared Resident 21's morning medications on the medication cart located at Nursing Station 1. LVN 1 walked to Resident 21's room and did not take the medication cart with him. LVN 1 stated, the medication cart was approximately 12 feet away from Resident 21's room. During a concurrent observation and interview on 2/19/25 at 8:43 a.m. with LVN 1, LVN 1 prepared Resident 11's loperamide 2mg on the medication cart located at Nursing Station 1. LVN 1 walked to Resident 11's room and did not take the medication cart with him. LVN 1 stated, the medication cart was approximately 17 feet away from Resident 11's room. During a concurrent observation and interview on 2/19/25 at 8:49 a.m. with LVN 1, LVN 1 had opened a lidocaine patch on the medication cart located at Nursing Station 1 for Resident 5. LVN 1 walked to Resident 5's room and did not take the medication cart with him. LVN 1 stated, the medication cart was approximately 30 feet away from Resident 5's room. During a concurrent observation and interview on 2/19/25 at 8:53 a.m. with LVN 1, LVN 1 prepared Resident 16's lorazepam on the medication cart located at Nursing Station 1. LVN 1 walked to the activities room to administer Resident 16's lorazepam and did not take the medication cart with him. LVN 1 stated, the medication cart was approximately 75 feet away from the activities room. During a concurrent observation and interview on 2/19/25 at 11:08 a.m. with LVN 1, LVN 1 prepared Resident 15's medications on the medication cart located at Nursing Station 1. LVN 1 walked to the activities room to administer Resident 15's medication and did not take the medication cart with him. LVN 1 stated, the medication cart was approximately 75 feet away from the activities room. During a concurrent observation and interview on 2/19/25 at 11:11 a.m. with LVN 1, LVN 1 prepared Resident 78's medication on the medication cart located at Nursing Station 1. LVN 1 walked to Resident 78's room and did not take the medication cart with him. LVN 1 stated, the medication cart was approximately 120 feet way from Resident 78's room. During a concurrent observation and interview on 2/19/25 at 11:16 a.m. with LVN 1, LVN 1 walked to Resident 8's room and administered his eye drops. LVN 1 did not bring the medication cart with him when we walked to Resident 8's room. LVN 1 stated, Resident 8's room was approximately 120 feet away from the medication cart located by Nursing Station 1. During a concurrent observation and interview on 2/19/25 at 11:16 a.m. with LVN 1, LVN 1 walked to Resident 8's room and administered his eye drops and did not bring the medication cart with him. LVN 1 stated, Resident 8's room was approximately 120 feet away from the medication cart located by Nursing Station 1. During a concurrent observation and interview on 2/19/25 at 11:19 a.m. with LVN 1, LVN 1 prepared Resident 14's medication on the medication cart located at Nursing Station 1. LVN 1 walked to Resident 14's room and did not bring the medication cart with him. LVN 1 administered Resident 14's breathing treatment (a therapy that uses inhaled medications to improve breathing) and checked her blood sugar with a glucometer. LVN 1 walked back to the medication cart after he finished and cleaned the glucometer at the medication cart. LVN 1 stated, Resident 14's room was approximately 17 feet away from the medication cart located by Nursing Station 1. During an observation on 2/19/25 at 11:26 a.m., LVN 1 walked back to Resident 14's room and did not take the medication cart. LVN 1 used an insulin syringe (small needle used to inject insulin) and administered Resident 14's insulin. LVN 1 left the room and walked back to the medication cart by Nursing Station 1. During a concurrent observation and interview on 2/19/25 at 11:35 a.m., LVN 1 walked to Resident 20's room to check her blood sugar with a glucometer and did not bring the medication cart with him. LVN 1 walked back to the medication cart located at Nursing Station 1 to clean the glucometer and prepare Resident 20's insulin. LVN 1 stated, Resident 20's room was approximately 17 feet away from the medication cart located by Nursing Station 1. During an observation on 2/19/25 at 11:41 a.m., LVN 1 held an insulin syringe and walked back to Resident 20's room. LVN 1 administered the insulin to Resident 20 and walked back to the medication cart while holding the insulin syringe. During an interview on 2/19/25 at 12:08 p.m., LVN 1 stated, he should have taken the medication cart with him each time he administered medications to a resident. LVN 1 stated, keeping the medication cart nearby was important to ensure all supplies were within reach and to avoid walking across the hallway, which helped prevent the risk for cross-contamination of medications to be administered to residents. During an interview on 2/19/25 at 2:01 p.m. with the IP, the IP stated nurses should have taken the medication cart with them while passing medications. The IP stated, having the medication cart nearby allowed the nurse to have immediate access to supplies or medications. The IP stated, walking back and forth between room and a distant medication cart posed a potential risk for cross-contamination. During an interview on 2/21/25 at 11:34 a.m. with the DON, the DON stated, nurses had to take the medication cart with them wherever they provided patient care. The DON stated, keeping the medication cart nearby allowed nurses to have immediate access to supplies and medications. The DON stated, walking back and forth between resident's room and a distant medication cart posed a potential risk for cross-contamination. During a review of the professional reference (PR) titled, CDC's Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings, found on www.cdc.gov/infection-control/hcp/core-practices/index.html , dated 4/12/24, the PR indicated, .Injection and Medication Safety .Prepare medications in a designated clean medication preparation area that is separated from potential sources of contamination .

Based on observation, interview, and record review, the facility failed to store and distribute food in accordance with professional standards for food service safety when the sink faucet was covered with a black and brown substance. This failure placed residents who consumed food prepared in the facility kitchen at risk for foodborne illness (a disease caused by consuming contaminated food or drink). Findings: During a concurrent observation and interview on 2/18/25 at 9:15 a.m., with the Dietary Supervisor (DS), in the kitchen, the sink faucet located near the dish washing machine was observed with a black and brown substance. The DS stated the base of the sink faucet was not clean and the sink faucet should be cleaned daily. During an interview on 2/19/25 at 1:53 p.m., with [NAME] 1, [NAME] 1 stated they were supposed to clean the sink faucet daily and it was not done. [NAME] 1 stated the 27 facility residents received their meals daily from the kitchen and could potentially get ill because of cross contamination (spread of harmful bacteria from one place or object to another). During an interview on 2/19/25 at 3:13 p.m., with the DS, the DS stated dietary staff were tasked to clean the sink faucet daily and it was not done. The DS stated facility residents were at risk for foodborne illness when food was not prepared in a clean environment. The DS stated, Cross contamination could cause illness to our residents. During a review of the facility's document titled, Job Description: Dietary Cook/Worker, undated, the document indicated, . Use all utensils and equipment in a safe and sanitary manner . During a review of the facility's policy and procedure (P&P) titled, Sanitation in Preparation and Serving, dated 7/11, the P&P indicated, . Strict adherence to the following rules will eliminate the hazard of food poisoning while food is being prepared and served . All equipment should be cleaned and sanitized before use .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1), who had a history of falls and was assessed as a high fall risk, received adequate supervision and assistance to prevent injuries when Resident 1 had five falls between 5/8/24 and 6/28/24. This failure placed Resident 1 at risk for continued falls and had the potential to result in injury. Findings: During an interview on 7/16/24 at 10:26 a.m. with the Director of Nursing (DON), the DON stated Resident 1 had a witnessed fall on 5/29/24. The DON stated Resident 1 complained of hip pain a half hour after the fall so an X ray (a procedure that uses high-energy radiation to take pictures of the inside of the body) was done which showed a small fracture in the pelvis (The area of the body below the abdomen that contains the hip bones, bladder, and rectum)which did not require hospitalization or surgery. During a review of Resident 1 ' s admission Record (AR), undated, the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnosis of coccidioidomycosis (a fungal infection in the lungs), malignant neoplasm (cancerous tumor) of prostate (walnut-sized gland in the male reproductive system), metabolic encephalopathy (chemical imbalance in the blood affecting the brains function), anxiety (feeling of fear, dread and uneasiness), and repeated falls. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], indicated Resident 1's Brief Interview for Mental Status (BIMS -assessment of cognitive status for memory and judgment) scored 9 out of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 1 was moderately cognitively impaired. During a review of Resident 1's X-ray result dated 5/30/24, the result indicated, . Chief Complaint: Pain in right hip . Findings . There is a recent versus subacute fracture [an older fracture which has begun to heal] of the right superior pubic ramus [a bone which makes up part of the pelvis] at the symphysis pubis [joint where the pubic bones meet] . If there is pain to palpation in this area . then CT scan [medical imagining to create detailed pictures of the inside of the body] of the pelvis is recommended . During a review of Resident 1's CT Pelvis w/o [without] Contrast [dye used to show abnormal areas in body], dated 6/4/24 was reviewed. The CT scan indicated, . Comminuted fracture [bone broken in at least two places] of the right pubic symphysis and extending into the superior pubic ramus with minimal displacement [change in position] and surrounding soft tissue edema [swelling] . During an observation on 7/16/24 at 10:43 a.m. in Resident 1's room, Resident 1's bed was empty because he was hospitalized due to an unrelated illness and there were two fall mats at his bedside. During an interview on 7/16/24 at 10:45 a.m., with Resident 2, Resident 2 stated he had been Resident 1's roommate for a few weeks but was not present during any of the falls. Resident 2 stated Resident 1 had an alarm which would go off when he tried to get out of bed, or his wheelchair and the staff would come running in to check on him. Resident 2 stated he had never seen Resident 1 receiving one on one supervision (clinical status unstable enough to require staff to observe them at all times) with staff. During an interview on 7/16/24 at 10:50 a.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated she was familiar with Resident 1. CNA 1 stated Resident 1 had frequent falls while in the facility. CNA 1 stated Resident 1 was alert but not oriented, impulsive and would not call for help. CNA 1 stated Resident 1 frequently got out of bed by himself when in his room alone which increased his fall risk. CNA 1 stated staff would take Resident 1 to activities or sit him by the nurse's station to provide extra supervision during the day which prevented falls. CNA 1 stated she worked the night shift at times and Resident 1 would frequently get out of bed when left alone. During an interview on 7/16/24 at 10:54 a.m. with CNA 2, CNA 2 stated Resident 1 was alert but forgetful. CNA 2 stated she was aware Resident 1 was a high fall risk. CNA 2 stated Resident 1 had an alarm on his bed and chair which would go off when he tried to get. CNA 2 stated, Someone always has an eye on him when he is up during the day. CNA 2 stated Resident 1 would not remember to use his call light for help. During a concurrent interview and record review on 7/16/24 at 12:26 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 1 was at high risk for falls. LVN 1 stated Resident 1 had interventions in place to prevent falls and injuries such as bed/chair position alarm, frequent visual checks, call light within reach, reminders to use call light, fall mats, the star program, bed low position and non-skid footwear. LVN 1 was unable to clarify the frequency of frequent visual checks. LVN 1 stated Resident 1 had frequent checks while he was out of his room in his wheelchair, but the checks were not done while he was in his room. LVN 1 stated the star program was used for residents at high fall risk. LVN 1 stated the therapy department would evaluate the resident and assign a red or white star depending on the amount of assistance they required, white stars indicated the resident was safe to ambulate alone and the red stars indicated the residents required assistance. LVN 1 stated Resident 1 was assigned a red star because he was not safe to ambulate or transfer by himself. LVN 1 reviewed Resident 1's diagnoses and stated Resident 1 had metabolic encephalopathy, confusion, history of falls and a urinary tract infection (UTI-bacteria grows in the urinary tract [the body's drainage system for removing urine]) which increased his fall risk. Resident 1' s Health Status Note, dated 5/29/24 at 0830 (8:30 a.m.), indicated, . [name of CNA] heard alarm coming from resident ' s room and walked in and noted resident standing in between the bed and the window . attempted to get to resident before he could move further . resident began walking forward . appeared to lose his balance and fell forward . resident denied pain at time of fall . Resident 1' s fall risk care plan initiated 5/9/24 was reviewed, the care plan indicated, . Resident at risk for falls R/T [related to] generalized muscle weakness, and poor safety awareness r/t intermittent episodes of confusion . unwitnessed non-injury fall in room [ROOM NUMBER]/8/24 . Witnessed fall in room [ROOM NUMBER]/14/24 . Unwitnessed fall in room [no date] with skin tear to right RA [fore arm] . Witnessed fall hit head, noninjury on 5/29/24 . Unwitnessed fall 6/28/24 . will remain free from falls through the next review period . Target Date 9/5/24 . Continue reminders to use call light . Bed in lowest position. Floor mats in place. Increase CNA rounding . Verbal reminders to not ambulate [walk]/transfer without assistance . bed alarm, increase CNA rounding at night . Delayed injury: right pubic rami fracture from witnessed fall confirmed 05/31/2024. RP [responsible party]/MD [physician] notified. Xray and radiology report given to Ortho [orthopedic - a physician specializing in treatment of the musculoskeletal system (bones, joints, ligaments, tendons, or muscles)] surgeon for evaluation . LVN 1 stated Resident 1' s mental status fluctuated throughout the day so interventions to educate or remind him to not get up alone or to use call light would be ineffective. LVN 1 stated the most effective interventions for Resident 1 was supervision and distraction because he did not fall when he was out of his room supervised. LVN 1 stated Resident 1 would need constant supervision to prevent falls. During a concurrent interview and record review on 7/16/24 at 1:30 p.m. with the DON, the DON stated Resident 1 had history of frequent falls prior to his admission. The DON stated Resident 1 fell on 5/29/24 but did not complain of pain when he was assessed. The DON stated Resident 1 complained of pain later in the day, so the nurse notified the physician and received an order for an X-ray of the hip. Resident 1' s Risk Benefit Analysis: High Fall Risk/Unavoidable Falls, dated 5/23/24 was reviewed and indicated, . The above-named patient has been identified as being a high-risk alert for falls . You/the Resident and family are encouraged to participate in the development of the plan of care. IT IS IMPROTANT THAT YOU ACKNOWLEDGE THAT THESE APPROACHES WILL NOT ABSOLUTELY PREVENT A FALL OR PREVENT SERIOUS INJURY FROM OCCURING . The interdisciplinary team [IDT-group of healthcare professionals who work together to provide care] has reviewed your/the residents fall risk associated with your/the resident' s medical and cognitive condition and have discussed approaches that may be included in your/the resident ' s plan of care . circle appropriate . Low bed [circled] . RNA/PT/OT [circled] . Toileting assistance [circled] . No being left alone in your own room [not circled] . The DON stated the interventions circled were active interventions. The DON stated the IDT had decided Resident 1' s falls were unavoidable. The DON stated the facility was responsible to keep the resident safe from falls. DON stated it would be too expensive to place Resident 1 on one on one. The DON stated Resident 1 had received every intervention but was still falling which made the falls unavoidable. The DON stated he fractured the pelvis but had a history of fracturing the same area in the past. During a telephone interview on 8/15/24 at 12:07 p.m. with LVN 2, LVN 2 stated he was the charge nurse on 5/29/24 when Resident 1 fell. LVN 2 stated he was at the nurse' s station and heard Resident 1' s bed alarm go off, so he walked down the hall to the room and saw CNA 3 walk into the resident' s room. LVN 2 stated when he walked into Resident 1' s room, the resident was laying face down shifted to his right side. LVN 2 stated the resident denied pain at the time, but within a half hour pointed to his right groin and said it hurt. LVN 2 stated Resident 1 was unable to verbalize his severity of pain using the numeric pain scale (based on 0-no pain, 1 to 3-mild pain, 4 to 6-moderate pain and 7-10 severe pain), so he utilized the FACES pain scale (visual scale to rate pain). LVN 2 stated the FACES pain scale indicated he was sore, not in moderate or severe pain. LVN 2 stated the resident denied severe pain. LVN 2 stated he notified the physician when Resident 1 complained of pain and was given an order for a hip X-ray. LVN 2 stated Resident 1 was not sent to the emergency department because he was not in a large amount of pain. I figured it was possibly just bruised. LVN 2 stated the physician declined to send the resident to the ED and wait for the X-ray results. LVN 2 stated the X-ray was done on 5/30/24 and the results were received on 6/1/24. LVN 2 stated the physician was notified of the X-ray results and he had ordered a CT scan. LVN 2 stated the resident was not sent to the hospital after the X-ray because the physician stated the injury was not normally fixed by surgery. LVN 2 stated Resident 1's pain was easily controlled by oral pain medication, and he did not require surgery or hospitalization for the injury. LVN 2 stated the physician was aware the resident had a fracture; the CT scan was a precaution to verify the resident did not require surgery. LVN 2 stated Resident 1's intervention of keeping up in activities was successful because he was supervised, and the staff could intervene before he got up and fell. LVN 2 stated Resident 1 had not been on a one-on-one supervision while in his room, but supervision was the most effective intervention to prevent him from falling. During a telephone interview on 8/15/24 at 12:35 p.m. with CNA 3, CNA 3 stated she was the CNA who had witnessed Resident 1' s fall on 5/29/24. CNA 3 stated Resident 1 had a mobility alarm on his bed which had gone off. CNA 3 stated she walked into the resident' s room and found him standing at bedside, when she had walked towards him, he fell. CNA 3 stated Resident 1 denied pain at the time of the fall. During a review of Resident 1' s Interdisciplinary Team Meeting, dated 5/30/24 was reviewed. The IDT note indicated, . Resident had a witnessed fall in room [ROOM NUMBER]/29/24 . approximately 08:30 am, CNA [name] heard alarm coming from resident room and walked in and noted resident standing in room in between the bed and the window . resident appeared to lose his balance and fell forward . Resident denied any pain at time of fall . approximately 40 minutes later resident complained of minimal right groin area . PMD (primary Medical Doctor) was notified and ordered X-ray of right hip . IDT met and unavoidable was put in place previous fall 5/22/24. Will keep encouraging resident to use call light . During a review of the facility' s policy and procedure (P&P) titled Assessing Falls and Their Causes, dated 7/2019, the P&P indicated, . Purpose . provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall . Falls are a leading cause of morbidity and mortality among the elderly in nursing homes . Falling may be related to underlying clinical or medical conditions . After a fall . evaluate for possible injuries to the head, neck, spine, and extremities . If there is evidence of injury, provide appropriate first aid and/or obtain medical treatment immediately . Observe for delayed complications of a fall for approximately seventy-two (72) hours . Document any observed signs or symptoms of pain, swelling, bruising, deformity and/or decreased mobility . During a review of the facility ' s P&P titled, Falls and Fall Risk, Managing and Prevention, dated 9/15/23, the P&P indicated, . the staff will identify interventions related to the resident ' s specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling . Staff will assist and supervise those residents that are at identified at risk for falls . The IDT staff, with the input of the attending physician, will implement a resident-centered fall prevention plan . If the resident has a current care plan for falls this care plan will be updated by adding the new fall to problem including date and short description of fall. A new approach will also be added Starting on date of new fall . If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions . All Residents determined to be at a risk for falls with a score of 10 or higher will be placed in the facility Fall Prevention Program to prevention injuries from fall .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement a resident-centered comprehensive care plan for two of three sampled residents (Resident 1and Resident 2), when: 1. Resident 1 was left unsupervised on 4/5/24 in the shower room resulting in fall. 2. Resident 2 ambulated without assistance on 4/18/24 in the facility hallway resulting in a fall. These failures resulted in Resident 1 and 2 falling to the ground and had the potential to result in injury. Findings: 1.During a review of Resident 1's admission Record (document containing resident demographic information and medical diagnosis) undated, the admission record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnosis included cognitive communication deficit (difficulty paying attention to a conversation, remembering information). During a concurrent observation and interview on 4/30/24 at 9:50 a.m., with Resident 1 in the dining room, Resident 1 was seated in her wheelchair. Resident 1 was unable to recall how she fell on 4/5/24. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive and physical function) Assessment dated 3/16/24, it indicated Resident 1's Brief Interview for Mental Status (BIMS -assessment of memory and judgment) assessment score was 7 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, 00-07 indicates severe impairment, 99 severely impaired). The BIMS assessment indicated Resident 1 had severe cognitive impairment. During a review of Resident 1 ' s Progress Notes (PN), dated 4/5/24 was reviewed. The PN indicated, .Resident was found lying on her left side next to shower hose in center shower room. Approximately 2 minutes prior, resident was assisted to the toilet in the shower room, CNA [certified nursing assistant] .left resident to get skin protectant cream. Upon CNA walking back into shower room, resident found lying on the floor . During a concurrent interview and record review on 4/30/24 at 11:47 a.m. with Licensed Vocational Nurse (LVN) 1, Resident 1 ' s Care Plan (CP) dated 6/2/23 was reviewed. The CP indicated, .is at risk for falls R/T [related to] generalized muscle weakness .Observe frequently and place in supervised area when out of bed . LVN 1 stated Resident 1 should not have been left unsupervised in the shower room. LVN 1 stated the care planned interventions should be implemented by all staff caring for Resident 1. During an interview on 4/30/24 at 2:01 p.m. with CNA 1, CNA 1 stated she left Resident 1 unsupervised in the shower room to get a cream. CNA 1 stated she heard a sound while walking back to the shower room and upon entering the shower room, she observed Resident 1 on the ground. CNA 1 stated she should not have left Resident 1 unsupervised in the shower room. During a concurrent interview and record review on 4/30/24 at 2:16p.m. with the Administrator (ADM), the facility policy and procedure (P&P) titled Care Planning dated 04/2024 was reviewed. The P&P indicated, . Care, treatment and services are planned to ensure they are appropriate to the resident ' s needs . Care planning will be implemented through the integration of assessment findings, consideration of the prescribed treatment plan and development of goals for the resident that are reasonable and measurable . The ADM stated care planned interventions should be implemented for the safety of residents. The ADM stated CNA 1 should have asked another staff to obtain the cream. 2. During a review of Resident 2's admission Record, undated, the admission record indicated, Resident 2 was admitted to the facility on [DATE]. Resident 1's diagnosis muscle weakness, difficulty walking, and Alzheimer ' s (affect a person ' s ability to carry out daily activities). During a concurrent observation and interview on 4/30/24 at 9:45 a.m., with Resident 2 in Resident 2 ' s room, Resident 2 was lying in bed. Resident 2 did not want to be interviewed regarding her fall. During a review of Resident 2's Minimum Data Set Assessment (MDSA) dated 3/2/24, MDSA indicated, Resident 2's Brief Interview for Mental Status assessment score was 6. The BIMS assessment indicated Resident 6 had severe cognitive impairment. During a review of Resident 2 ' s Progress Notes (PN), dated 4/18/24 was reviewed. The PN indicated, .Activities assistant .witnessed resident ambulating in the hallway with FWW [front wheel walker] .Resident was turning left to walk into the lobby and appeared to lose her balance. Resident fell on her back, walker fell over to right side .copious amounts of blood coming from back of head with lacerations noted to back of head. Resident noted to have skin tear to top of right hand, and discoloration to left elbow .Resident appeared confused, unable to say what happened . During a telephone interview on 4/30/24 at 10:31 a.m. with Activity Assistant (AA), AA stated on 4/18/24 she was doing activities with residents when she observed Resident 2 ambulating in the hallway unsupervised. AA stated Resident 2 stumbled and fell backwards. During a concurrent interview and record review on 4/30/24 at 10:51 a.m. with LVN 1, Resident 2 ' s Care Plan (CP) dated 12/12/23 was reviewed. The CP indicated, .Risk for falls .Assist Resident with ambulation and transfers, utilizing therapy recommendations . LVN 1 stated Resident 1 needed assist when ambulating because she was not steady when ambulating. During a phone interview on 4/30/24 at 11:02 a.m. with Physical Therapy (PT), PT stated Resident 2 needed supervision when ambulating in the hallway. PT stated Resident 2 needed verbal cues for safety because she had confusion. During a review of Resident 2 ' s Therapist Progress & Discharge Summary dated 1/25/24, indicated, .ambulates 200 feet on level surfaces with front wheeled walker and modified independence (assistive device or extra time needed) and verbal instruction/cues .Due to safety reasons, the patient requires verbal cues for all functional mobility . During a concurrent interview and record review on 4/30/24 at 2:16p.m. with the ADM, the facility policy and procedure (P&P) titled Care Planning dated 04/2024 was reviewed. The policy indicated, . Care, treatment and services are planned to ensure they are appropriate to the resident ' s needs . Care planning will be implemented through the integration of assessment findings, consideration of the prescribed treatment plan and development of goals for the resident that are reasonable and measurable . The ADM stated care planned interventions should be implemented for the safety of residents. During a telephone interview on 5/3/24 at 2:13 p.m. with CNA 2, CNA 2 stated she was the assigned CNA for Resident 2 on 4/18/24. CNA 2 stated she was getting water on the other side of the hallway when Resident 2 fell. CNA 2 stated Resident 2 would lose balance at times when she was ambulating. CNA 2 stated whenever she observed Resident 2 walking, she would walk next to Resident 2 because she was at risk of losing her balance and falling.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to revise and implement a person centered comprehensive care plan for one of three sampled residents (Resident 1), when Resident 1 fell on 4/5/24 and care plan interventions were not revised and updated. This failure placed Resident 1 ' s health and safety at risk when fall care plan interventions were not revised. Findings: During a review of Resident 1's admission Record (document containing resident demographic information and medical diagnosis) undated, the admission record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnosis included cognitive communication deficit (difficulty paying attention to a conversation, remembering information). During a concurrent observation and interview on 4/30/24 at 9:50 a.m., with Resident 1 in the dining room, Resident 1 was seated in her wheelchair. Resident 1 was unable to recall how she fell on 4/5/24. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive and physical function) Assessment dated 3/16/24, indicated Resident 1's Brief Interview for Mental Status (BIMS -assessment of memory and judgment) assessment score was 7 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, 00-07 indicates severe impairment, 99 severely impaired). The BIMS assessment indicated Resident 1 had severe cognitive impairment. During a review of Resident 1 ' s Progress Notes (PN), dated 4/5/24 was reviewed. The PN indicated, .Resident was found lying on her left side next to shower hose in center shower room. Approximately 2 minutes prior, resident was assisted to the toilet in the shower room, CNA [certified nursing assistant] .left resident to get skin protectant cream. Upon CNA walking back into shower room, resident found lying on the floor . During a concurrent interview and record review on 4/30/24 at 11:47 p.m. with Licensed Vocational Nurse (LVN) 1, Resident 1 ' s Care Plan (CP) dated 6/2/23 was reviewed. The CP indicated, .is at risk for falls R/T [related to] generalized muscle weakness .Observe frequently and place in supervised area when out of bed . LVN 1 reviewed Resident 1 care plans and stated there were no updated interventions after the fall on 4/5/24. LVN 1 stated care plan interventions should be updated after a fall, but was not. During an interview on 4/30/24 at 2:01 p.m. with CNA 1, CNA 1 stated she left Resident 1 unsupervised in the shower room to get a cream. CNA 1 stated she heard a sound while walking back to the shower room and upon entering the shower room she observed Resident 1 on the ground. CNA 1 stated she should not have left Resident 1 unsupervised in the shower room. During a concurrent interview and record review on 4/30/24 at 2:20p.m. with the Administrator (ADM), the facility policy and procedure (P&P) titled Falls and Fall Risk, Managing and Prevention dated 09/2023 was reviewed. The policy indicated, . Based on previous evaluations and current data, the staff will identify interventions related to the resident ' s specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling .The IDT (Interdisciplinary Team) staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls . The ADM stated care planned interventions should be updated and revised of falls. The ADM stated the importance of the care plan was to implement interventions to keep residents safe.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide care in a manner that maintained or enhanced a resident's dignity and respect when one of one sampled resident (Resident 26)'s foley catheter (an indwelling urinary catheter - a thin tube placed in the bladder to drain urine into a bag) drainage bag was without a dignity bag (a bag used to the cover and hold the catheter drainage/collection bag so it is not visible). This failure violated Resident 26's privacy and had the potential to affect the self-esteem, self-worth, and quality of life of Resident 26. Findings: During a concurrent observation and interview on 2/27/24 at 12:30 p.m. with Resident 26 in the hallway outside Resident 26's room, Resident 26 was observed in a wheelchair with his foley catheter bag hooked on the side of his wheelchair, uncovered. Resident 26 stated he had been at the facility for a while. Resident 26 did not want to answer further questions. During a review or Resident 26's admission Record (AR), dated 3/1/24, the AR indicated Resident 26 was admitted on [DATE] with diagnoses of follicular lymphoma (Cancer of the lymph nodes [small, bean-shaped organs that filter substances in the body and contain cells that fight infection]), acute kidney failure (a condition when the kidneys suddenly are unable to filter waste products from the blood), and Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks). During a review of Resident 26's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 2/19/24, the MDS section C indicated Resident 26 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive understanding on a scale of 1-15 ) score of 7 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 26 was severely cognitively impaired. During an interview on 2/28/24 at 10:05 a.m. with Certified Nursing Assistant (CNA) 2, CNA 2 stated if the urine bag was not covered it was not good. CNA 2 stated the drainage bag should be in the dignity bag so it was not seen and tubing should not touch the floor. During an interview on 2/29/24 at 8:55 a.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated it was important to have a dignity bag covering the drainage bag which should have been covered. LVN 2 stated the dignity bag covered the urine which could be a dignity issue for Resident 26. During an interview on 2/29/24 at 9:33 a.m. with the Director of Nursing (DON), the DON stated her expectation was that residents catheters were in a dignity bag and placed under the resident's wheelchair. The DON stated this was to preserve residents' privacy and dignity. The DON stated it was not appropriate to have Resident 26's drainage bag uncovered. During an interview on 3/01/24 at 3:18 p.m. with the Administrator (ADM), the ADM stated his expectation was for the residents catheters to not be seen and that the tubing was off the floor. The ADM stated if the bag was uncovered, it was not preserving Resident 26's dignity.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement comprehensive person-centered care plans (CP - a detailed approach to care customized to an individual resident's needs) for four of 12 sampled residents (Residents 4, 10, 24 and 26) when: 1. Residents 4, 10, and 24 did not have an individualized care plan developed and implemented for the use of side rails. This failure had the potential for Residents 4, 10, and 24 to be injured while using the side rails. This failure had the potential for Residents 4, 10, and 24 to be injured while using the side rails. 2. Resident 26 did not have an individualized care plan developed and implemented for the use of a dignity bag (a bag used to cover and hold the [NAME] catheter [an indwelling urinary catheter - a thin tube placed in the bladder to drain urine into a bag] drainage/collection bag so it is not visible). This failure violated Resident 26's privacy and had the potential to affect the self-esteem, self-worth, and quality of life of Resident 26. Findings: 1. During a review of Resident 4's admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 2/29/24, the AR indicated, Resident 4 was admitted from home on 1/26/24 to the facility, with diagnoses that included Anxiety (A mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), Hypertension (high blood pressure), Atrial fibrillation (Afib, is an irregular and often very rapid heart rate), and Arthritis (inflammation or swelling of joints). During a concurrent interview and record review with Licensed Vocational Nurse (LVN) 1, on 2/29/24, at 10:22 a.m., Resident 4's nursing Care Plan (CP) was reviewed. LVN 1 stated Resident 4 had a risks and benefits form for side rail use and consent (a permission for something to happen or agreement to do something) signed by family consenting to the use of side rails on 1/26/24. LVN 1 reviewed Resident 4's CP and stated there was no CP developed for the use of side rails. LVN 1 stated the use of side rails should have been care planned to include interventions such as bed inspection, frequent visual checks and monitoring of side rails for continued use. LVN 1 stated the CP for side rails should have been developed when the consent was signed by Resident 4's responsible party (RP). During a review of Resident 10's AR, dated 2/29/24, the AR indicated, Resident 10 was admitted from an acute care hospital on 1/19/24 to the facility, with diagnoses which included Senile Degeneration of Brain (memory loss), Dementia (impaired ability to remember, think, or make decisions), Hypertension, Type 2 Diabetes Mellitus (high blood sugar), and Cerebral Infarction (stroke). During an observation on 2/27/24, at 10:42 a.m., in Resident 10's room, Resident 10 was sleeping and laying in bed, on his back, with half-length side rails up on both sides of the bed. During a concurrent interview and record review with LVN 2, on 2/29/24, at 10:01 a.m., Resident 10's nursing CP was reviewed. LVN 2 stated Resident 10 had a risks and benefits form for side rail use completed on 1/19/24 and the consent signed by the RP consenting to the use of side rails on 2/1/24. LVN 2 reviewed Resident 10's CP and stated there was no CP developed for the use of side rails. LVN 2 stated the use of side rails should have been care planned to include interventions to prevent risks of entrapment, injury, and monitoring for continued use. LVN 2 stated the CP for side rails should have been developed when the consent was signed by Resident's RP and after obtaining a physician order. During a review of Resident 24's AR, dated 2/29/24, the AR indicated, Resident 24 was admitted from an acute care hospital on [DATE] to the facility, with diagnoses which included Urinary Tract Infection (UTI- bladder infection), Myocardial Infarction (heart attack), Cardiomyopathy (is a disease of the heart muscle that makes it harder for the heart to pump blood to the rest of the body), Pneumonia (lung infection caused by bacteria), and Multiple Sclerosis (commonly known as MS, is a long-lasting disease which can cause problems with vision, balance, muscle control, and other body functions). During a concurrent interview and record review with LVN 2, on 2/27/24, at 2:52 p.m., Resident 24's nursing CP was reviewed. LVN 2 stated Resident 24 had a risks and benefits form for side rail use and consent signed by Resident 24 [self-responsible] consenting to the use of side rails on 11/1/23. LVN 2 reviewed Resident 24's CP and stated there was no CP developed for the use of side rails. LVN 2 stated the use of side rails should have been care planned to include interventions to prevent risks of entrapment, injury, and monitoring for continued use. LVN 2 stated the CP for side rails should have been developed when the consent was signed by Resident 24's and after obtaining a physician order. During an interview with the Director of Nursing (DON), on 3/1/24, at 12:26 p.m., the DON stated upon reviewing the risks and benefits form for side rail use and obtaining the consent from the RP, a physician order should be obtained from the attending physician and a CP should be developed. The DON stated the CP drove resident care to ensure residents care was being met. The DON stated the facility failed to follow the facility's P&P related to care planning process. During a review of the facility's policy and procedure (P&P) titled Care Plans, Comprehensive Person-Center dated 3/22, the P&P indicated, . The comprehensive, person-centered care plan is developed .no more than 21 days after admission . The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment . a. includes measurable objectives and timeframes; b. describe the services that are to be furnished to attain or maintain resident's highest practicable physical, mental, and psychosocial well-being . During a review of the facility's P&P titled Bed Safety and Bed Rails dated 6/23, the P&P indicated, . Resident beds meet the safety specifications established by the administration team . 2. The use of bed rails or side rails is prohibited unless the criteria for use of bed rails have been met, including attempts to use alternative, interdisciplinary evaluation, resident assessment, and informed consent . During a review of the facility's document titled, Job Description: Licensed Vocational Nurse, undated, the document indicated, . Essential Job Functions include, but are not limited to the following . Assessment of Residents . Following all facilities Policies and Procedures . Perform other duties as requested . 2. During a concurrent observation and interview on 2/27/24 at 12:30 p.m. with Resident 26 in the hallway outside Resident 26's room, Resident 26 was observed in a wheelchair with his Foley catheter bag hooked on the side of his wheelchair, uncovered. Resident 26 stated he had been at the facility for a while. Resident 26 did not want to answer further questions. During a review or Resident 26's admission Record (AR), dated 3/1/24, the AR indicated Resident 26 was admitted on [DATE] with diagnoses of follicular lymphoma (Cancer of the lymph nodes [small, bean-shaped organs that filter substances in the body and contain cells that fight infection]), acute kidney failure (a condition when the kidneys suddenly are unable to filter waste products from the blood), and Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks). During a review of Resident 26's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 2/19/24, the MDS section C indicated Resident 26 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive understanding on a scale of 1-15 ) score of 7 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 26 was severely cognitively impaired. During an interview on 2/29/24 at 9:33 a.m. with the Director of Nursing (DON), the DON stated her expectation was resident's catheters were in a dignity bag and placed under the resident's wheelchair. The DON stated this was to preserve residents' privacy and dignity. The DON stated it was not appropriate to have Resident 26's urine bag uncovered. The DON stated the facility needed to provide a better care plan for Resident 26. During a review of the facility's policy and procedure (P&P) titled, Comprehensive Care Plan dated 7/2013, indicated, . a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . During a review of Resident 26's Care Plan (CP), (undated), the CP indicated no care plan in place for a Foley catheter dignity bag for Resident 26.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide fire safety accommodations to ensure the residents remained safe while they smoked for four of four sampled residents (Residents 7, 9, 10 and 24), when Residents 7, 9, 10, and 24 were not provided with noncombustible (non flammable) aprons prior to smoking cigarettes. This failure had the potential to place the residents at risk for smoking related injuries. Findings: During a review of Resident 7's admission Record (AR), dated 3/1/24, the AR indicated Resident 7 was admitted on [DATE] with diagnoses of 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), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities), and muscle weakness. During a review of Resident 7's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 2/19/24, the MDS section C indicated Resident 7 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive understanding on a scale of 1-15 ) score of 15 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 7 was cognitively intact. During a review of Resident 7's Care Plan (CP), dated, 2/11/24, the CP indicated, . Resident will adhere to the Tobacco/Smoking Policies of the Facility . educate Resident/Responsible Party (RP) on the facility's tobacco/smoking policy(s) . During an observation on 2/29/24 at 11:07 a.m. outside in the smoking area, Resident 7 was observed sitting in her wheelchair smoking a traditional cigarette. Resident 7 was observed not wearing a noncombustible apron. During a review of Resident 9's AR, dated 3/1/24, the AR indicated Resident 9 was admitted on [DATE] with a diagnosis of dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). During a review of Resident 9's MDS, dated 1/23/24, the MDS section C indicated Resident 9 had a BIMS score of 14 out of 15 which suggested Resident 9 was cognitively intact. During a review of Resident 9's CP, dated 1/24/24, the CP indicated, . Resident will adhere to the Tobacco/Smoking Policies of the Facility . educate Resident/Responsible Party (RP) on the facility's tobacco/smoking policy(s) . During a concurrent observation and interview on 2/29/24 at 10:46 a.m. with Resident 9 in her room, Resident 9 was observed sitting in her wheelchair by her door. Resident 9 stated she smoked, and she had a smoking schedule. Resident 9 stated staff did not tell her about smoking safety. Resident 9 stated she did not wear a smoking apron when she smoked. During an observation on 2/29/24 at 11:07 a.m. outside in the smoking area, Resident 9 was observed sitting in her walker smoking an electronic cigarette (e-cig) next to residents smoking traditional cigarettes. Resident 9 was observed not wearing a noncombustible apron. During a review of Resident 10's AR, dated 3/1/24, the AR indicated, Resident 10 was admitted on [DATE] with a diagnosis of dementia. During a review of Resident 10's MDS, dated 1/30/24, the MDS Section C indicated Resident 10 had a BIMS score of 9 out of 15, which suggested Resident 10 was moderately impaired. During a review of Resident 10's CP, dated (undated), the CP indicated, . Resident will adhere to the Tobacco/Smoking Policies of the Facility . Resident will not suffer injury from unsafe smoking practices . staff to extinguish cigarettes . During an observation on 2/29/24 at 11:07 a.m. outside in the smoking area, Resident 10 was observed sitting in his wheelchair smoking a traditional cigarette. Resident 10 was observed not wearing a noncombustible apron. During a review of Resident 24's AR, dated 3/1/24, the AR indicated Resident 24 was admitted on [DATE] with a diagnosis of multiple sclerosis (a condition where body attacks itself) During a review of Resident 24's MDS, dated 1/25/24, the MDS indicated, Resident 24 had a BIMS score of 15 out of 15, which suggested Resident 24 was cognitively intact. During a review of Resident 24's CP, dated 12/28/23, the CP indicated, . the resident will not smoke without supervision through the review date . instruct resident about the facility policy on smoking; locations, times, safety concerns . notify charge nurse immediately if it is suspected resident has violated facility smoking policy . the resident requires SUPERVISION while smoking . During an observation on 2/29/24 at 11:07 a.m. outside in the smoking area, Resident 24 was observed sitting in her wheelchair with an assistant smoking a traditional cigarette. Resident 24 was observed not wearing a noncombustible apron. During a concurrent observation and interview on 2/29/24 at 11:12 a.m. with the Activities Assistant (AA) outside the facility in the designated smoking area, the AA was observed giving the residents their smoking articles, no noncombustible aprons were observed in the AA's possession. The AA stated the residents lit their own cigarettes. The AA stated the residents flicked the cigarette ashes on the ground. The AA stated the residents did not like to wear the noncombustible apron. The AA stated she was not sure if the residents were educated on safety while smoking. During a concurrent interview and record review on 3/1/24 at 3:18 p.m. with the Administrator (ADM), the facility's policy and procedure (P&P) titled, Smoking Policy - Residents dated 7/20 was reviewed. The P&P indicated, . this facility shall establish and maintain safe resident smoking practices . resident must apply the noncombustible apron prior to smoking . The ADM stated he was not aware the P&P stated the residents must wear a noncombustible apron. The ADM stated the staff needed to follow the P&P. The ADM stated there could be inconsistencies in resident care and resident safety if the P&Ps were not followed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure medical records were complete and accurately documented in accordance with accepted professional standards of practice for four of 12 sampled residents (Residents 1, 12, 17, and 26) when Resident 1, 12, 17 and 26's copy of Physician Orders for Life-Sustaining Treatment (POLST - a medical order signed by both the patient and medical provider that specifies the types of medical treatment a patient wishes to receive toward the end of life) were incomplete. This failure had the potential for the Resident 1, 12, 17 and 26's decisions regarding treatment options and end of life wishes to not be honored. Findings: During a review of Resident 1's admission Record (AR), dated [DATE], the AR indicated, Resident 1 was admitted on [DATE] with diagnoses of anoxic brain damage (brain damage due to a complete lack of oxygen to the brain), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities), and cortical blindness (loss of vision due to damage of the visual pathways 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 [DATE], the MDS, section C indicated Resident 1 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive understanding on a scale of 1-15 ) score of 99 indicating Resident 1 was not interviewable (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact). During a concurrent interview and record review on [DATE] at 8:55 a.m. with Licensed Vocational Nurse (LVN) 2, Resident 1's POLST, dated [DATE] was reviewed. The POLST indicated, no physician phone number documented on the POLST. LVN 2 stated Resident 1's POLST was not complete. LVN 2 stated the purpose of a completed POLST was to know what the residents' wishes were for life sustaining treatment. LVN 2 stated if the POLST was not completed with the Doctor or guardian's phone number, the receiving facility would not be able to contact the guardian or the Doctor. LVN 2 stated if the resident was transferred to another facility, the facility would want to call the Doctor. During a review of Resident 12's AR, dated [DATE], the AR indicated Resident 12 was admitted on [DATE] with diagnoses of fracture of upper and lower end of the fibula (a break in the smaller of two bones in the lower leg), and chronic kidney disease (a condition in which the kidneys are damaged and cannot filter waste from the blood as well as they should). During a review of Resident 12's MDS, dated [DATE], the MDS indicated Resident 12 had a BIMS score of 15 out of 15, which suggested Resident 12 was cognitively intact. During a concurrent interview and record review on [DATE] at 9:03 a.m. with LVN 2, Resident 12's POLST, dated [DATE] was reviewed. LVN 2 stated page 2, which included patient name, patient date of birth , patient gender, (Nurse Practitioner/Physician's Assistant (NP/PA)'s supervising physician information, the POLST preparer's name, and additional contact names. LVN 2 stated page 2 of Resident 12's POLST was not filled out. LVN 2 stated Resident 12's POLST was not completed. During a review of Resident 17's AR, dated, [DATE], the AR indicated Resident 17 was admitted on [DATE] with diagnoses of dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), heart failure (a condition when the heart muscle doesn't pump enough blood to meet the body's needs which can cause fatigue and shortness of breath), and fracture of right femur (a break in the thigh bone). During a review of Resident 17's MDS, dated [DATE], the MDS indicated Resident 17 had a BIMS score of 14 out of 15, which suggested Resident 17 was cognitively intact. During a concurrent interview and record review on [DATE] at 8:55 a.m. with LVN 2 Resident 17's POLST, dated [DATE] was reviewed. LVN 2 stated Resident 17's POLST was not completed accurately. LVN 2 stated the purpose of a completed POLST was to know what the resident's wishes were, whether to do Cardiopulmonary Resuscitation (an emergency procedure consisting of chest compressions often combined with mouth-to-mouth breathing in a person who's heart has stopped beating and is no longer breathing) (CPR) or not. LVN 2 stated Resident 17's POLST was not clear, Do Not Attempt Resuscitation/DNR (do not perform CPR, allow a natural death) and Full Treatment (primary goal of prolonging life by all medically effective means) were marked. LVN 2 stated if the POLST was not completed correctly, staff and emergency personnel would not know the resident's wishes for life sustaining treatment. During a review of Resident 26's AR, dated [DATE], the AR indicated Resident 26 was admitted on [DATE] with diagnoses of follicular lymphoma (Cancer of the lymph nodes [small, bean-shaped organs that filter substances in the body and contain cells that fight infection]), acute kidney failure (a condition when the kidneys suddenly are unable to filter waste products from the blood), and Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks). During a review of Resident 26's MDS, dated [DATE], the MDS indicated Resident 26 had a BIMS score of 7 out of 15, which suggested Resident 26 was severely cognitively impaired. During a concurrent interview and record review on [DATE] at 9:06 a.m. with LVN 2, Resident 26's POLST, dated [DATE] was reviewed. LVN stated Resident 26's POLST was not completed. LVN 2 stated the Doctor's printed name and phone number were not completed and page 2, of Resident 26's POLST. LVN 2 stated the purpose of a completed POLST was to know what the resident's wishes were. LVN 2 stated if the POLST was not completed with the Doctor's phone number or if it did not have the guardian's phone number, staff and emergency personnel would not be able to contact the Doctor if the resident was sent to another facility. LVN 2 stated staff would want to call the Doctor. During a concurrent interview and record review on [DATE] at 9:33 a.m. with the Director of Nursing (DON), the DON stated her expectation was for the POLST forms to be completed. The DON stated she mis-read the instruction on completing the POLST page 2 and thought that page 2 did not need to be completed. The DON stated the form disclosed to other facilities what care was necessary for the residents life sustaining treatment. During a concurrent interview and record review on [DATE] at 3:18 p.m. with the Administrator (ADM), Resident 1's POLST, dated [DATE] was reviewed. The ADM stated Resident 1's POLST was contradictory. The ADM stated both boxes were marked Do Not Attempt Resuscitation/CPR and Full Treatment. The ADM stated we would not know to save the Resident or not. The ADM stated if the POLST was incomplete without the physician's phone number, we would not be able to get in touch with the physician. The ADM stated the POLST was for residents' wishes for life sustaining treatment to be known and fulfilled. Add the policy of POLST

Based on interview and record review, the facility failed to follow its hospice (care that focuses on the quality of life for people who are experiencing an advanced, life-limiting illness) policy and procedures for two of two sampled residents (Residents 2 and 10) when the facility failed to ensure that hospice personnel caring for residents under hospice services were provided orientation to the facility's policies and procedures and staff were not aware of who was the designated hospice coordinator. This failure had the potential to place Residents 2 and 10 at risk of not receiving appropriate medical, physical, psychosocial, and spiritual support to manage symptoms associated with terminal illness. Findings: During a review of Resident 2's admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 3/1/24, the AR indicated, Resident 2 was admitted from an acute care hospital on 4/23/19 to the facility, with diagnoses which included Dementia (a decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities), Hypertension (high blood pressure), Repeated Falls, Atrial fibrillation (Afib, is an irregular and often very rapid heartbeat), Hemorrhage of Cerebrum (stroke, bleeding inside the brain), and Atherosclerotic Heart Disease (hardening of veins causing limited blood flow and could result to stroke). During a review of Resident 2's Order Summary Report (OSR), dated 11/17/23, the OSR indicated, . Admit to [Name of Hospice Agency] Diagnosis: Atherosclerotic Heart Disease . During a review of Resident 10's AR, dated 2/29/24, the AR indicated, Resident 10 was admitted from an acute care hospital on 1/19/24 to the facility, with diagnoses which included Senile Degeneration of Brain (memory loss), Dementia, Hypertension, Type 2 Diabetes Mellitus (high blood sugar), and Cerebral Infarction (stroke). During a review of Resident 10's Order Summary Report (OSR), dated 1/19/24, the OSR indicated, . Admit to [Name of Hospice Agency] Diagnosis: Senile Degeneration of Brain . During an interview on 3/1/24, at 12:35 p.m., with [Hospice Agency] Hospice Social Worker (HSW), HSW stated he was the assigned Hospice Social Worker for Resident 2 and Resident 10 and have been coming to the facility since April 2022. HSW stated he visited Resident 2 and Resident 10 once a week and provided psychosocial and emotional support. HSW stated he did not recall having an orientation on the facility's policy and procedures or meeting the facility's Hospice Coordinator. HSW stated, I thought the facility's Social Services Director (SSD) was the designated Hospice Coordinator. During an interview on 3/1/24, at 12:47 p.m., with Certified Nurse Assistant (CNA) 1 and CNA 2, in the main hallway, CNA 1 and CNA 2 both stated they currently have two residents receiving hospice care [Resident 2 and Resident 10] and the SSD was the facility's designated Hospice Coordinator. During an interview on 3/1/24, at 12:50 p.m., with the Infection Preventionist (IP-professional who ensures healthcare workers and patients are doing all the things they should to prevent infections), in the main hallway across the nurses's station, the IP stated the SSD was the facility's designated Hospice Coordinator. During a concurrent interview and record review, on 3/1/23, at 12:54 p.m., with the Social Services Director (SSD), the facility's Policy and Procedure (P&P) titled Hospice Program, dated 7/2017 was reviewed. The P&P indicated, . 12. Our facility has designated [blank space, no name and no title] to coordinate care provided to the resident by our facility staff and the hospice staff .e. Ensuring that our facility staff provides orientation on the P&P of the facility, including resident rights, appropriate forms, and record keeping requirements, to hospice staff furnishing care to the residents . The SSD stated she coordinated the hospice referral and family meeting for hospice evaluation but she did not know the facility's designated Hospice Coordinator. The SSD stated she was not aware of any orientation conducted on the facility's P&P to hospice staff. The DSD stated the facility failed to follow its own hospice P&P. During a concurrent interview and record review, on 3/1/23, at 2:30 p.m., with the Director of Nursing (DON), the facility's P&P titled Hospice Program, dated 7/2017 was reviewed. The P&P indicated, . 12. Our facility has designated [blank space, no name and no title] to coordinate care provided to the resident by our facility staff and the hospice staff .e. Ensuring that our facility staff provides orientation on the P&P of the facility, including resident rights, appropriate forms, and record keeping requirements, to hospice staff furnishing care to the residents . The DON stated she was the facility's designated Hospice Coordinator and not the SSD. The DON stated she did not have any record or proof that an orientation on the P&P of the facility to hospice staff caring for facility residents was done. The DON stated the facility failed to follow its own hospice policy. The DON stated the lack of orientation to the facility's policy and procedure to hospice personnel could potentially result to not meeting the medical, physical, psychosocial, and spiritual needs of Residents 2 and Resident 10. During a review of the facility's P&P titled, Hospice Program, dated 7/2017, the P&P indicated, . Hospice services are available to residents at the end of life . 12. Our facility has designated [blank space, no name and no title] to coordinate care provided to the resident by our facility staff and the hospice staff .e. Ensuring that our facility staff provides orientation on the P&P of the facility, including resident rights, appropriate forms, and record keeping requirements, to hospice staff furnishing care to the residents . 13. Coordinated care plans for residents receiving hospice services . in order to maintain the resident's highest practicable physical, mental and psychosocial well-being .

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. One of one drawer that stored clean utensils had dried food on a spatula. This 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. Five unlabeled food items and two expired food items were found in the resident nourishment refrigerator and kitchen refrigerators. These failures placed residents at risk for cross contamination and had the potential to cause foodborne illness (illness caused by ingestion of contaminated food or beverages) to 28 of 28 residents who consumed the food . Findings: 1. During a concurrent observation and interview on 2/27/24 at 9:26 a.m. with the Kitchen Supervisor (KS) in the kitchen, the clean utensil drawer was observed to have a spatula with dried, caked on yellow food particles mixed in with clean utensils. The KS observed the dirty spatula and stated the spatula was not clean. The KS stated the spatula should not be in the clean utensil drawer. The KS stated all the utensils in the clean utensil drawer needed to be removed and reprocessed. During an interview on 2/28/24 at 1:37 p.m. with the Registered Dietician (RD), the RD stated dirty cooking utensils should not be in the clean cooking utensil drawer. The RD stated her expectations of the kitchen was that it be clean and sanitized to prevent the risk of cross contamination and residents getting sick from food borne illness. During an interview on 3/01/24 at 11:54 a.m. with the KS, the KS stated the dirty utensils probably got into the clean utensil drawer after the dishes were washed. The KS stated staff might have just grabbed the utensils and put them in the drawer without checking to be sure they were clean. The KS stated it was important to get food particles off the utensils. The KS stated dirty utensils could lead to cross-contamination. The KS stated using dirty utensils could get the residents sick. During an interview on 3/01/24 at 3:18 p.m. with the Administrator (ADM), the ADM stated dirty utensils should not be in the clean utensil drawer. The ADM stated his expectation was for the kitchen to be clean and sanitary. The ADM stated having dirty utensils in the clean utensil drawer could cause cross contamination and food born illness to the residents. During a review of the facility's policy and procedure (P&P) titled, Sanitation and Infection Control . Dishwashing Procedures (Dish machine), dated 2023, indicated, . all the dishes should be inspected after coming out of the dish machine and if the dishes are not clean then they should be washed again in the dish machine . During a review of the KS job description titled, Orientation, Inservice, & Personnel Management . Director of Food and Nutrition Services Job Description dated 2023, indicated, . ensures sanitation and safety standards are maintained according to State, Federal, and local regulations . During a review of professional reference titled, FDA Food Code 2022, section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, dated 2022, indicated, . EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch .the FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations . During a review of professional reference titled, FDA Food Code 2022, section 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles, dated 2022, indicated, . cleaned EQUIPMENT and UTENSILS, laundered LINENS, and SINGLE-SERVICE and SINGLE-USE ARTICLES shall be stored . in a clean, dry location . where they are not exposed to splash, dust, or other contamination . During a review of professional reference titled, FDA Food Code 2022, section 4-602.13 Nonfood-Contact Surfaces, dated 2022, indicated, . 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 02/27/24 at 9:33 a.m. with [NAME] (CK) 1 in the walk-in refrigerator in the kitchen, a package of raspberries with a white substance on them was observed. CK 1 stated the raspberries looked like they had mold on them. Three bowls of chopped vegetable food items were observed in Refrigerator #1 without labels. CK 1 stated the vegetables were chopped this morning. CK 1 stated she did not put a label on the food items. During a concurrent observation and interview on 2/28/24 at 10:50 a.m. with the RD in the staff lounge, the Resident Nourishment Refrigerator was observed to have an unlabeled food container, shriveled, discolored tomatoes in a container labeled 10/11/23, and an opened jar of food with a received date of 9/29/23, without an opened date label. The Resident Freezer was observed to have cloth ice packs with resident names on them, unwrapped. The RD stated there should not be unlabeled and expired food in the resident refrigerator. The RD stated there should not be medical equipment in the resident freezer. During an interview on 2/28/24 at 11:06 a.m. with the KS, the KS stated the resident food was held only three days in the resident nourishment refrigerator. The KS stated the night shift kitchen staff checked the resident refrigerator. The KS stated the freezer packs were for nurses to use, not the residents. The KS stated the dietary department did not use the Resident Freezer. During an interview on 2/28/24 at 1:37 p.m. with the RD, the RD stated her expectations for storing resident food was it be labeled and dated with an opened date, used by dated and dated when prepared or received. The RD stated there should not be expired food or unlabeled food in the resident refrigerator. The RD stated if residents were served expired food or outdated food, they could become sick. During an interview on 2/29/24 at 8:55 a.m. with LVN 2, LVN 2 stated the dietary department monitored the resident refrigerator. LVN 2 stated we did not let residents keep personal food. LVN 2 stated we would not save the resident's food. LVN 2 stated nursing did not keep track of resident's food. LVN 2 stated storing the ice packs in the resident freezer was not a good idea. LVN 2 stated it could cause cross contamination. LVN 2 stated if ice packs leaked, they could leak out into the resident's food. During an interview on 2/29/24 at 9:33 a.m. with the Director of Nursing (DON), the DON stated the facility had a policy and procedure (P&P) for the resident nourishment refrigerator. The DON stated staff were required to follow those policies. The DON stated it was not appropriate for other departments to put medical equipment in the resident refrigerator. The DON stated the dietary department was responsible for the resident refrigerator. The DON stated nursing staff would get the resident's food from the resident refrigerator. The DON stated if the food was expired, the resident could get sick. The DON stated she would expect the dietary department to follow daily checks of the resident refrigerator. The DON stated if there was expired food in the resident refrigerator it needed to be thrown away immediately. The DON stated expired food should not be in the refrigerator. During an interview on 3/01/24 at 3:18 p.m. with the ADM, the ADM stated his expectation was for the resident refrigerator to be clean and sanitary. The ADM stated no expired food should be in the refrigerators. The ADM stated eating expired food could cause foodborne illness. The ADM stated no medical equipment should be in the resident refrigerator or freezer. The ADM stated there would be a potential for cross-contamination and food borne illness from bacteria. During a review of the facility's P&P titled, Sanitation and Infection Control . Food Brought in From Outside Sources, dated 2023, indicated, . All food brought in should be checked by the charge nurse or the Director of Food and Nutrition Services. It must be placed in a tightly sealed container with the resident's name and date on it . Food that does not have a manufacturer's printed date must be thrown out 3 days from the time it was brought in .

Based on observation, interview and record review, the facility failed to ensure resident was treated with dignity and respect for one of three residents (Resident 6) when Certified Nursing Assistant (CNA)2 stood over Resident 6 while spoon feeding him his lunch. This failure resulted in Resident 6 not being provided a respectful and dignified dining experience which could further enhance resident's quality of life. Findings: During an observation on 11/15/22, at 12:10 p.m., in Resident 6's room, Resident 6 was laying in bed with head of bed elevated, bedside table on the side of the bed. CNA was standing on the side of Resident 6's bed while spoon-feeding him his lunch and CNA was also wearing disposable gloves. During a review of Resident 6's Minimum Data Set (MDS - an assessment tool used develop and implement the care plan), dated 9/9/22, indicated, . Eating . Extensive assistance . During a review of Resident 6's Care Plan, undated, indicated, . Eating: - The resident requires (extensive assistance) by (1p [one person]) staff to eat . During an interview on 11/16/22, at 12:48 p.m., with CNA 2, CNA 2 stated she usually sits down when assisting residents during meals. CNA 2 stated, . I did not know why I did not sit when I assisted resident, I was just used to standing up when I feed him . CNA 2 stated she should have sat down when she assisted Resident 6 during lunch meal. During an interview on 11/17/22, at 11:01 a.m., with the Licensed Vocational Nurse (LVN)1, LVN 1 stated the CNA's were supposed to be sitting when assisting residents during meals. LVN 1 stated the CNA's were supposed to be at eye level with the resident when assisting during meals. During an interview on 11/17/22, at 12:09 p.m., with Infection Preventionist (IP), the IP stated the nursing staff should not be standing while assisting residents during meals. The nursing staff should be sitting down when assisting residents during meals because it is a dignity issue. During an interview on 11/18/22, at 9:53 a.m., with the Director of Nursing (DON), the DON stated nursing staff should not be standing when assisting residents during meals to be at eye level with the resident. DON stated it is a dignity issue. During a review of facility's Policy and Procedure (P&P) titled, Resident Rights, dated 8/2019, the P&P indicated, be treated with respect, kindness and dignity . be supported by the facility in exercising his or her rights . During a review of facility's Policy and Procedure (P&P) titled, Assistance with Meals, dated 11/18/22, the P&P indicated, . Residents Requiring Full Assistance: . Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity, . not standing over residents while assisting with meals .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a physician obtained informed consent (IC) for the use of psychotropic medication (medication capable of affecting mind, emotions, and behavior) of one of three sampled residents (Resident 11) when Resident 11 received an increase in the dosage of Divalproex Sodium (medication to treat convulsion (uncontrolled shaking of the body) and psychosis[trouble distinguishing which of their perceptions [interpretation or understanding of] and thoughts are real and which are not]) without obtaining an informed consent from the Responsible Party (R/P) and or Resident 11. This failure resulted in Resident 11 receiving the medication and not being fully informed of the risk and benefits of psychotropic medication being administered and not making an informed choice and possibly placed at risk of negative side effects. Findings: During a concurrent observation and interview on 11/15/22, at 10:10 a.m., in room [ROOM NUMBER], Resident 11 was laying in bed with eyes closed. Resident 11 stated he had been in the facility all his life and did not have any concerns. During a review of Resident 11's clinical record titled, admission Record (document with resident demographic information) dated 11/18/22, indicated Resident 11 was admitted on [DATE], with diagnosis which included unspecified psychosis, dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) . Review of Resident 11's clinical record titled, Order Summary Report, dated 11/18/22, indicated, . Divalproex Sodium tablet Delayed release 125 MG (milligram-unit of measurement) (Divalproex Sodium) Give 1 (one) tablet by mouth three times a day related to UNSPECIFIED PSYCHOSIS NOT DUE TO A SUBSTANCE OR KNOWN PHYSIOLOGICAL CONDITION M/B (manifested by) aggression when redirecting resident for excessive behaviors . Start Date 11/04/21 . During a concurrent interview and record review on 11/17/22, at 2:45 p.m., with Minimum Data Set Nurse (MDSN), the MDSN reviewed Resident 11's clinical record titled, Informed Consent To Receive Medications undated. The MDSN stated the informed consent for Divalproex Sodium 125 mg 1 (one) po (by mouth) QD (daily) was signed by Resident 11's Responsible Party (R/P) on 9/4/20. The MDSN reviewed Resident 11's clinical record titled, RISKS VS. BENEFITS FORM, undated. The MDSN stated the risks vs benefits form was signed by Resident 11's R/P on 11/16/22. The MDSN stated the medication order: Divalproex Sodium 125 mg 1 tab QD. The MDSN stated the informed consent was not updated after the medication was increased. The MDSN stated the informed consent should have been updated and signed by the R/P when the dose was increased. The MDSN stated, . Medication can not be given without the signed consent because the medication was a mind altering medication . During an interview on 11/18/22, at 9:53 a.m., with the Director of Nursing (DON), the DON stated the consents for psychotropic medications needed to be signed by the Medical Doctor (MD) and the family. The DON stated the facility also do the risk and benefits of medications and the MD and family has to sign the form. The DON stated the medication can not be given to the resident without a signed consent. During a review of the facility's policy and procedure (P&P) titled, Informed Consent, dated 11/18/22, the P&P indicated, It is the policy of this facility that the resident must be given the opportunity to give an informed consent prior to the administration of psychotherapeutic drugs . It is the attending physician's responsibility to obtain the informed consent . An informed consent must be obtained before the ordered may be carried out by the nursing staff .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure the accuracy of Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive and physical function) assessment for one of six sampled residents (Resident 4) when section J- Pain management was not accurately coded on the quarterly MDS assessment dated [DATE]. This failure had the potential for Resident 4 to not receive individualized pain management based on Resident 4's specific needs. Findings: During a review of Resident 4's admission Record (document containing resident demographic information and medical diagnosis), dated 11/17/22, the admission record indicated Resident 4 was admitted to the facility on [DATE]. Resident 4's diagnosis included .OTHER CHRONIC PAIN (long standing pain that persists beyond the usual recovery period) .MUSCLE WEAKNESS (a lack of muscle strength) .OTHER DISORDER OF CIRCULATORY SYSTEM (any disorder or condition that affects the circulatory system and can occur because of problems with the heart, blood vessels or the blood) . During a review of Resident 4's MDS Assessment, dated 8/3/22, the MDS indicated, Resident 4's Brief Interview for Mental Status (BIMS -an evaluation of attention, orientation and memory recall) score of 13 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment), indicating Resident 4 had no cognitive impairment. During a review of Resident 4's Quarterly MDS J-Pain Management (section J), dated 11/2/22, section J indicated, .At any time in the last 5 days, has the resident: Received scheduled pain medication regimen? .No . During a review of Resident 4's Order Summary Report active orders, dated 11/17/22, the Order Summary Report active orders indicated, .[name brand of pain medication] 200 [milligrams- unit of measurement]-2 tablets by mouth at bedtime [daily], order date 5/24/22 During a concurrent interview and record review, on 11/17/22, at 12 p.m., with Minimum Data Set Nurse (MDSN), Resident 4's Order Summary Report active orders, dated 11/17/22 was reviewed. The Order Summary Report active orders indicated, Resident 4 had orders for (brand name pain medication) 200 milligrams (mg), 2 tablets nightly at bedtime for the treatment of chronic pain (long standing pain that persists beyond the usual recovery period). MDSN validated the pain medication order on the Order Summary Report active orders. MDSN stated, the pain medication order was missed on the 11/2/22 MDS Quarterly Assessment. During a concurrent interview and record review, on 11/17/22, at 12:05 p.m., with MDSN, Resident 4's MDS section J- pain management (section J) assessment, dated 11/2/22 was reviewed. MDSN validated, section J, did not indicate the appropriate coding for Resident 4. The MDSN stated section J indicated Resident 4 did not receive scheduled pain medication within the 5-day assessment reference date (ARD-the specific end point of look-back periods in the MDS assessment process) which consists of ARD plus 4 previous calendar days. During a review of the facility's Resident Assessment Instrument/Minimum Data Set manual (RAI/MDS- a comprehensive assessment and care planning procedure manual used by the nursing home), dated 10/19, the RAI/MDS indicated, .Steps for Assessment . Review medical record to determine if a pain regimen exists . Review the medical record and interview staff and direct caregivers to determine what, if any, pain management interventions the resident received during the 5-day ARD lookback period (ARD-the specific end point of look-back periods in the MDS assessment process) which Consists of ARD + 4 previous calendar days. Include information from all disciplines. Coding Instructions for J0100A-C [To] Determine all interventions for pain provided to the resident during the 5-day look-back period . During a review of the facility's policy and procedure (P&P) titled, Certifying Accuracy of the Resident MDS Assessment, dated 7/19, the P&P indicated, .All personnel who complete any portion of the Resident Assessment must sign and certify the accuracy of that portion of the assessment .

Based on interview, and record review the facility failed to maintain an effective system for receiving, reconciling, and identifying missing controlled drugs (medications with potential for abuse or addiction and are required by federal law to be accounted for by licensed nurses), for two of nine sampled residents (Resident 5 and Resident 10) when the facility did not implement a system to reconcile controlled medications consistently and accurately. This failure had the potential for diversion (used illegally) of controlled substance medications. Findings: During a concurrent interview and record review on 11/15/22, at 10:30 a.m., with the Director of Nursing (DON), medication delivery manifests (list of residents' medications received by facility from pharmacy) dated for Residents 5 and 10 were reviewed. The DON stated, the process at the facility for receiving controlled drugs was one LVN would receive the drug from the pharmacy and sign the delivery manifest verifying they received the medication. The DON stated, the facility did not keep the controlled drug receipts records separate from the non-controlled drugs manifest receipt records, and she did not know the process to track or audit-controlled drugs received in the facility. During a review of the facility's document, [Contracted Pharmacy] Shipping Manifest . Date: 06/09/22 . [Resident 5] . CLONAZEPAM 1 MG Tablet . [quantity] 60.000 . Received by [underlined area that was blank] . Date . [underlined area that was blank] (verify receipt) . During a review of the facility's document, [Contracted Pharmacy] Shipping Manifest . Date: 06/26/22 . [Resident 10] . HYDROCODONE - ACETAMIN 5-325 MG . [quantity] 90.000 . Received by [underlined area with one signature] . Date . [underlined area with date 6/26/22] (verify receipt) . During an interview, on 11/15/22, at 10:59 a.m., with the DON, the DON validated delivery manifests for Resident 5 and Resident 10 did not have double signatures. DON stated, the facility's process for receiving controlled drugs should have been that a double signature (two licensed nurses) on the receipt record for the controlled drugs when it was received at the facility. The DON stated, that the facility's policy and procedure for controlled drugs was not being followed. The DON stated, there was a potential for controlled drugs to be diverted if the policy and procedure was not followed. During an interview on 11/18/22, at 11:49 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, the process at the facility for receiving controlled drugs was one nurse would verify the medication order was correct on the manifest and sign that they received the medication. LVN 1 stated, the receipt records for controlled drugs and non-controlled drugs were kept together in the same binder. LVN 1 stated, he did not know the process for auditing-controlled drugs in the facility. LVN 1 stated, if controlled medications were not signed by two nurses or audited at the facility there was a potential for resident's medications to go missing or be diverted. During a review of the facility's policy and procedure (P&P) titled, Controlled Substance Acquisition and Distribution for [facility name], dated 5/30/2006, the P&P indicated, Purpose and Scope: To ensure that controlled substances are handled according to federal and state laws and to prevent diversion of controlled medications . If anyone other than the pharmacist receives controlled substances in the facility, a double signature of two licensed nurses (the Director of Nursing and the Charge nurse) will be required to acknowledge the receipt of the medication and to record the receipt of the medication in the perpetual history . All controlled substance receipts and dispositions will be recorded on perpetual inventory records .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with current accepted professional principles for two of four sampled residents (Resident 18 and Resident 25) when: 1. Resident 18's Novolin R (a short-acting insulin that lowers blood sugar levels) had no open date (date it was opened and first used) and discard or expiration date. 2. Resident 25's Latanoprost (a medication that treats high pressure inside the eye) had expired and was not discarded and was not labeled correctly. These failures had the potential for Novolin to be administered past the discard date to Resident 18 which could result in less effective medication and uncontrolled blood sugar and for Latanoprost to be administered past the discard date to Resident 25 which could result in uncontrolled eye pressure. Findings: During a concurrent observation and interview on [DATE], at 10:01 a.m., with Licensed Vocational Nurse (LVN) 1 at med cart 1, Resident 18's vial of Novolin was found with a label indicating DATE OPENED . [lined area underneath that was blank] . discard 47 days after opening . DISCARD ON . [lined area underneath that was blank] . LVN 1 stated, the Novolin should have been labeled with an open date and discard date. LVN 1 stated, that if the Novolin was not labeled with an open date and a discard date the medication could be given after it should have been discarded. LVN 1 stated, there was a potential for Resident 18 to receive Novolin that was less effective. Resident 25's bottle of Latanoprost was found with a label indicating DATE OPENED . [DATE] . discard 42 days after opening . DISCARD ON . [DATE] . LVN 1 stated, the Latanoprost should have been discarded on [DATE]. LVN 1 stated, Resident 25's Latanoprost would be less effective if administered after discard date. LVN 1 stated, there was a potential for Resident 25 to get an infection if the Latanoprost was given after the discard date. During a review of Resident 18's admission RECORD (AR), dated [DATE], the AR indicated, . DIAGNOSIS INFORMATION . UNSPECIFIED GLAUCOMA (a condition of increased pressure within the eyeball, causing gradual loss of sight) . During a review of Resident 18's Order Summary Report (OSR), dated [DATE], the OSR indicated, . [Resident 18] . Latanoprost Solution 0.005 % Instill 1 drop in both eyes at bedtime for Glaucoma . During a review of Resident 25's admission RECORD (AR), dated [DATE], the AR indicated, . DIAGNOSIS INFORMATION . TYPE 2 DIABETES MELLITUS (a chronic condition that affects the way the body processes blood sugar) WITHOUT COMPLICATIONS . During a review of Resident 25's Order Summary Report (OSR), dated [DATE], the OSR indicated, . [Resident 25] . NovoLIN R Solution . Inject as per sliding scale . subcutaneously before meals and at bedtime for Diabetes . During an interview on [DATE], at 12:14 p.m., with the Director of Nursing (DON), the DON stated, Resident 25's Latanoprost should have been discard on [DATE]. The DON stated, medications at the facility should not be administered after the discard date. The DON stated, Resident 25's Latanoprost would be less effective if administered after the discard date. The DON stated, Resident 18's Novolin should have had an open date and a discard date on the vial. The DON stated, if the Novolin was not labeled with an open date and a discard date the Novolin could be administered after the discard date. The DON stated, if the Novolin was administered after the discard date it would be less effective. During a review of Lexicomp, a nationally recognized drug reference, the manufacturer for Novolin R stated, . Storage/Stability . Store unopened vials in refrigerator between [36 degrees Fahrenheit to 46 degrees Fahrenheit] until expiration date or at room temperature of [less than or equal to] 86 degrees for [less than] 40 days . Store vials currently opened (in use) in a refrigerator or a room temperature . and discard after 40 days . when vials are stored at room temperature, vials may only be used for a total of 40 days, including both unopened and opened storage time . During a review of Lexicomp, a nationally recognized drug reference, the manufacturer for Latanoprost stated, . Storage/Stability Solution: store intact bottles under refrigeration at . [36 degrees Fahrenheit] to [46 degrees Fahrenheit] . Once opened, the container may be stored at room temperature up to [77 degrees Fahrenheit] for 6 weeks . During a review of the facility's policy and procedure (P&P) titled, Medications [undated], the P&P indicated, . All medication maintained in the facility are properly labeled in accordance with current state and federal guidelines and regulations . Labels for individual resident medications include all necessary information, such as: . The expiration date when applicable: and directions for use .

Based on dietetic services interviews, and record reviews, the facility failed to ensure the Registered Dietitian had effective oversight of the food and nutrition department in accordance with the facility executed contract and standards of practice. These failures resulted in severe unplanned weight loss for one of 28 residents (Resident 15) and had the potential to result in 28 out of 28 sampled residents risk of exposure to foodborne illness (stomach illness acquired from ingesting contaminated food), compromised nutrition status and further compromised resident's medical status. (Cross reference 692, 802, 803, 805, 806, and 812) Findings: During an interview on 11/16/22, at 8:41 AM, with the Registered Dietitian (RD). The RD stated, she had been worked at the facility since April 2022, for a total of 16 - 20 hours per month. The RD was scheduled in the facility every Monday for 4 hours. During an interview on 11/16/22, at 5:20 PM, with the RD. The RD stated, at the end of her services on Monday she provided a report to the Administrator (ADM), Director of Nursing (DON), Infection Preventionist (IP), and Dietary Service Supervisor (DSS). The RD validated, she did not follow up with the reported findings until the next visit because that was the responsibility of the DSS. During an interview on 11/17/22, at 3:32 PM, with the RD. The RD stated, the standard of practice as a consultant dietitian in Skilled Nursing Facility was to conduct residents' nutrition assessment, check for dietary sanitation and oversight of the Food and Nutrition Department. The deficiency findings were reviewed with the RD: a. Resident 15 experienced severe unplanned weight loss, Resident 15 had no interview completed for their personal goal weight, the RD did not analyze the root cause of weight loss (cross reference 692); b. unsanitary practices in Food and Nutrition services (cross reference 812); c. dietary staff was not safe and effective in food and nutrition services they did not know the right location to check the dish machine sanitizer, they did not know the right concentration of the dish machine sanitizer, they did not know how to calibrate the thermometer, they did not know the proper steps for the cool down process (cross reference 802) ; d. dietary staff changed the menu without a prior RD consult and substituted an unequal nutrition food group (cross 803); e. Dietary staff served the incorrect diet texture for mechanical soft residents (cross reference 805); f. Dietary staff did not honor Resident 26's food preferences (cross refereed 806). The RD stated, she lacked oversight of the food and nutrition department because she did not have enough hours in the facility. During an interview on 11/18/22, at 8:18 AM, with Administrator (ADM) and Administrator in Training (AIT), ADM and AIT validated, the RD lacked oversight of the food and nutrition department. ADM stated, It is embarrassment that I did not know, and it will be taken care of immediately. AIT stated, he would get involved in food and nutrition department and reevaluate the RD. During a review of the facility's Dietitian contract titled, Agreement to Provide Consultant Service, dated on 11/19/2019, the Dietitian contract indicated, Responsibilities of the consultant .The RDN will provide Consultation as follows. 1. Provides consultation to administration regarding planning, policy development, and priority-setting, based on initial and ongoing evaluation of the food service needs. 2. Offers in services education to facility staff .5. Counsels the resident .nutritional needs. 6. Assess resident's nutritional needs.9. Reviews sanitation in accordance with current regulatory standards General .2. The RDN shall make recommendations necessary to comply with all rules and regulations of the federal, state, .or department applicable to said food service facility or to the service of meals therein .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. During a review of the facility's document AR, dated 11/18/22, the AR indicated Resident 4's admission date at the facility was 7/25/2018. The AR indicated Resident 4 had the diagnosis of unspecified dementia, mild with other behavioral disturbance onset date of 7/25/2018 and unspecified psychosis (a severe mental disorder in which thoughts and emotions are so impaired that contact is lost with external reality) not due to a substance or known physiological condition onset date of 7/30/2019. During a review of the facility's document OSR, dated 11/18/22, the OSR indicated Resident 4 had an order for Quetiapine 100 milligram (MG) give 1 tablet at bedtime related to unspecified psychosis not due to a substance or known physiological condition ordered on 5/24/21 and discontinued on 10/5/21. The OSR indicated, Resident 4 was currently receiving Quetiapine 50 MG give 1 tablet two times a day for psychosis manifested by: agitation, aggression, crying, hallucination ordered on 5/09/22. During a concurrent interview and record review, on 11/17/22, at 10:01 a.m., with the MDS, Resident 4's Care Plan dated 10/03/22 was reviewed. The Care Plan indicated, . Focus . The resident uses psychotropic medications [Quetiapine.] . [related to] psychosis [manifested by] Agitation aggression, crying hallucination . Goal . The resident will be/remain free of psychotropic drug related complications, including movement disorder, discomfort, hypotension, gait disturbance, constipation/impaction or cognitive/behavioral impairment through review date . The MDS stated, Resident 4's care plan for quetiapine did not have a measurable goal. The MDS stated, Resident 4's care plan should have had a measurable goal. During an interview on 11/17/22, at 4:17 p.m., with the Director of Nursing (DON) the DON stated, residents care plans should have objective measurable goals and timeframes. The DON stated, it was important to have measurable goals to see if the goals are being met and the interventions working. The DON stated, if the goals were not met, the care plan should be revised. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered dated 3/2022, the P&P stated, . A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . The comprehensive, person-centered care plan . includes measurable objectives and timeframes . The interdisciplinary team reviews and updated the care plan: . when the desired outcome is not met . 4. During a review of the facility's document admission RECORD (AR), dated 11/17/22, the AR indicated Resident 16's admission date at the facility was 2/27/2019. The AR indicated Resident 16 had the diagnosis of unspecified dementia (a disorder marked by memory disorders, personality changes and impaired reasoning) unspecified severity, without behavioral disturbance, psychotic (loss of reality) disturbance and anxiety with onset date of 2/27/2019 and schizoaffective disorder (a mental health condition including schizophrenia and mood disorder symptoms), unspecified onset date of 2/27/2019. During a review of the facility's document ORDER SUMMARY REPORT (OSR), dated 11/18/22, the OSR indicated Resident 16 had medication orders for Aripiprazole 5 milligrams MG Give 1 tablet by mouth in the evening related to Schizoaffective Disorder. During a concurrent interview and record review, on 11/16/22, at 2:58 p.m., with the Minimum Data Set Nurse (MDS), Resident 16's Care Plan for Aripiprazole, dated 8/20/21 (revision on 1/16/22), was reviewed. The Care plan indicated, . The resident uses psychotropic medications [Aripiprazole] 5mg daily [times] on month then 10mg daily indefinite [related to] hallucination of episodes of psychosis: visual hallucinations of lights, ghosts etc. for use of [Aripiprazole] . Goal . The resident will be/remain free of psychotropic drug related complications, including movement disorder, discomfort, hypotension, gait disturbance, constipation/impaction or cognitive/behavioral impairment with less episodes of hallucinations of lights, ghosts etc. weekly and through review date . The MDS stated, Resident 16's care plan did not have an objective measurable goal. The MDS stated, Resident 16's care plan should have had a way to measure if he was meeting the goal. The MDS stated if a resident was not meeting his goal the doctor should have been notified. The MDS stated it was important to have a measurable goal because if a resident was not meeting their goal, it could mean the Aripiprazole needed to be adjusted. During an interview on 11/17/22, at 4:17 p.m., with the Director of Nursing (DON) the DON stated, residents care plans should have objective measurable goals and timeframes. The DON stated, it was important to have measurable goals to see if the goals are being met and the interventions working. The DON stated, if the goals were not met, the care plan should be revised. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered dated 3/2022, the P&P stated, . A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . The comprehensive, person-centered care plan . includes measurable objectives and timeframes . The interdisciplinary team reviews and updated the care plan: . when the desired outcome is not met . Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 4 of XX sampled residents (Resident 3, Resident 6, Resident 4 and Resident 16) when: 1. Resident 3 did not have a person centered care plan to address the use of oxygen. This failure resulted in Resident 3's oxygen needs going unmet and caused Resident 3 received oxygen at different rate. 2. Resident 6's hospice (program that gives special care to people who are near the end of life and have stopped treatment to cure or control their disease) care was not care planned when admitted to hospice care on 9/14/22. This failure had the potential in Resident 6's hospice needs going unmet. 3. Resident 4's care plan for psychotropic Quetiapine did not have an objective measurable goal. This failure had the potential to result in Resident 4 to receive unnecessary psychotropic medication and decreased psychosocial wellbeing. 4. Resident 16's care plan for psychotropic Aripiprazole did not have an objective measurable goal. This failure had the potential for Resident 16 to receive unnecessary psychotropic medication and decreased psychosocial wellbeing. Findings: 1. During a review of Resident 3's admission Record (a document containing resident profile information) dated 11/15/22, indicated Resident 3 was admitted to the facility on [DATE] with diagnosis which included heart failure, chronic atrial fibrillation (irregular and often very rapid heart rhythm that can lead to blood clots in the heart) and chronic ischemic heart disease (narrowed heart arteries). During an observation on 11/15/22, at 11:55 a.m., in Resident 3's room, Resident 3 laid in bed with oxygen via nasal cannula (plastic device used to deliver supplemental oxygen) receiving 4L/min (four Liters [unit of measurement]). Resident 3 did not respond when spoken to. During a review of Resident 3's care plan dated 10/18/22, the care plan indicated, . Focus: The resident has oxygen therapy r/t (related to) SOB (shortness of breath) . Interventions: Oxygen Settings: 02 (oxygen) via (SPECIFY: nasal prongs) @ (at) (2 [two]) L (liter) (QHS [hour of sleep] and PRN [as needed]) . During a concurrent interview and record review on 11/16/22, at 8:35 a.m., with Licensed Vocational Nurse (LVN 1), LVN 1 reviewed Resident 3's clinical record titled, Care Plan, dated 10/18/22. LVN 1 stated Resident 3's oxygen care plan is not individualized. LVN 1 stated, . Make sure to address the situation on hand and ensure it was done correctly . LVN 1 stated Resident 3's oxygen care plan could be better. 2. During an observation on 11/15/2022, at 10:15 a.m., in Resident 6's room in room [ROOM NUMBER], Resident 6 was observed laying in bed, eyes closed, covered with blanket and low pressure mattress used. Resident 6 did not respond when spoken to. During a review of Resident 6's admission Record, dated 11/17/22, the admission Record indicated, Resident 6 was admitted to the facility on [DATE], with diagnosis which included Cerebrovascular Disease (stroke- blood flow to a part of the brain is stopped either by a blockage or the rupture of a blood vessel) . During a concurrent interview and record review on 11/15/22, at 2:57 p.m., with LVN 2, LVN 2 reviewed Resident 6's clinical record for a care plan for Hospice. LVN 2 stated there was no care plan specific for Hospice. LVN 2 reviewed Resident 6 care plans and stated, . Care plan, Focus: Advanced Directives: DNR [Do Not Resuscitate] Goals: Resident's Advanced Directives Wishes Will Be Known. Interventions: Hospice care as ordered. Review Advanced Directives on file, if applicable. LVN 2 stated the interventions are not individualized to the resident, the facility should have done more. LVN 2 stated, . There should have a separate care plan to address resident on Hospice . During a concurrent interview and record review on 11/16/22, at 8:55 a.m., with LVN 1, LVN 1 reviewed Resident 6's clinical record titled, Care Plan, dated 11/15/22. LVN 1 stated Resident 6 was evaluated and admitted to Hospice on 9/14/22 and the care plan for Hospice was dated 11/15/22. LVN 1 stated the care plan should have been initiated right away after resident was admitted to hospice care. LVN 1 stated nurses are responsible in initiating care plans immediately. During an interview on 11/18/22, at 9:53 a.m., with the Director of Nursing (DON), the DON stated the nurse on-duty was in charge of initiating the care plan when receiving the order. The DON stated she also checked the care plan and add interventions as needed. The DON stated the Interdisciplinary Team (IDT- team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) reviews and modify care plan as needed. The DON stated she did not how the IDT missed Resident 3 and Resident 6's care plan. During a review of the facility's policy and procedure (P&P), titled, Baseline Care Plans, dated 11/17/22, the P&P indicated, . The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meets professional standards of quality of care and must include the minimum healthcare information necessary to properly care for the resident . The baseline care plan is updated as needed to meet the resident's needs until the comprehensive care plan is developed . A comprehensive care plan may be used in placed of the baseline care plan providing the comprehensive care plan is developed within 48 hours of the resident's admission and meets the requirements of a comprehensive assessment .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide services which met professional standards of quality of care for one of three sampled residents (Resident 3) when Resident 3's oxygen (a colorless, odorless, tasteless gas essential to living organisms) flow rate (the amount of oxygen being delivered to the body) was not administered according to the physician order (an order given for specific patient/resident by a health care provider). This failure resulted in Resident 3 not obtaining the ordered amount of oxygen via the oxygen concentrator ( a machine that pulls in the air around you), which could lead to breathing problems that include shortness of breath, headache, and confusion. Findings: During a review of Resident 3s admission Record (document containing resident demographic information and medical diagnosis), dated 11/18/22, the admission Record indicated, Resident 3 was admitted to the facility on [DATE]. Resident 3's diagnosis included .ESSENTIAL (PRIMARY) HYPERTENSION (occurs when you have abnormally high blood pressure that's not the result of a medical condition) .CHRONIC ATRIAL FIBRILLATION (is an irregular and rapid heart rhythm that can lead to blood clots in the heart) .CHRONIC ISCHEMIC HEART DISEASE ( a mismatch between the hearts oxygen supply and demand) . ATHEROSCLEROTIC HEART DISEASE OF NATIVE CORONARY ARTERY WITHOUT ANGINA PECTORIS (when the blood vessels that carry oxygen become thick and stiff which restricts blood flow) . During a review of Resident 3's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive and physical function) Assessment, dated 10/6/22, the MDS indicated Resident 3's Brief Interview for Mental Status (BIMS -an evaluation of attention, orientation and memory recall) score of 15 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment), indicating Resident 3 had no cognitive impairment. During an observation on 11/15/22, at 11:55 a.m., the flow rate (the amount of oxygen being delivered to your body) on the Oxygen concentrator (machine that pulls in the air around you) indicated 4.5 liters (L-a unit of measurement) per minute via (through) nasal cannula (a tube used to deliver supplemental oxygen through the nose). During an observation on 11/16/15, at 8:30 a.m., Where?, Resident 3's oxygen concentrator flow rate was observed at 4.5 liters per minute. During a concurrent observation and interview on 11/16/22, at 8:32 a.m., with Certified Nursing Assistant (CNA) 1, in Resident 3's room, Resident 3's oxygen concentrator flow rate was 4.5 liter per minute. CNA 1 stated, the oxygen concentrator flow rate is set at between 4-5 liters per minute. CNA 1 stated, licensed nurses set up the oxygen concentrator flow rate. CNA 1 stated, if there is an issue with the oxygen certified nurse assistants notify the licensed nurses. During a concurrent observation, interview and record review on 11/16/22, at 8:35 a.m., in Resident 3's room. Licensed Vocational Nurse (LVN) 1 verified Resident 3 was on the oxygen concentrator. LVN 1 stated, Resident 3's oxygen flow rate was set at 4.5 liters per minute on the oxygen concentrator. LVN 1 stated, she thought the order was for 2 liters per minute and she was not sure why the setting was at 4.5 liters per minute. LVN 1 stated, she did not do an assessment of Resident 3's oxygen needs at the beginning of her shift. LVN 1 reviewed, Resident 3's doctor's order summary (a document used to authorize what was ordered by a patient's treating/prescribing physician) active order's dated 11/15/22. LVN 1 stated, . The oxygen concentrator order flow rate is 2 liters per minute . LVN 1 stated, .I should have verified and assessed residents' oxygen settings . LVN 1 stated, the oxygen concentrator should have been set at 2 liters per minute not 4.5 liters per minute. LVN 1 stated, she did not check Resident 3's oxygen concentrators flow rate at the beginning of her shift. LVN 1 stated, it may be harmful to Resident 3 if Resident 3 did not receive the appropriate amount of oxygen per doctor's orders. During an interview on 11/18/22, at 9:52 a.m., with Director of Nursing (DON), DON stated, she considered oxygen a medication. DON stated, if a resident received the wrong flow rate with their oxygen it could affect their lungs, it could do more harm than good. During a review of facility's policy and procedure (P&P) titled, MEDICATION ADMINISTRATION, dated 3/2011, the P&P indicated, . the individual administering the medication will verify the medication selected for administration is the correct medication based on the medication order .Medications will be administered only upon the order of physicians . Administration will be by . registered nurse, licensed practical/vocational nurse . During a review of , Chowchilla Memorial Healthcare District JOB DESCRIPTION LICENSED VOCATIONAL NURSE, undated, the Chowchilla Memorial Healthcare District JOB DESCRIPTION LICENSED VOCATIONAL NURSE indicated, .Essential Job Functions include, but are not limited to .Administration of medications, treatments, procedures as ordered by physician .Assessments of Residents . During a review of facility's P&P titled, STANDARD OF PRACTICE STANDARD OF CARE SUBJECT: Oxygen Administration, dated 7/2019, the P&P indicated, . Review physicians orders .Observe the resident upon setup and periodically thereafter to be sure oxygen is being tolerated . During a professional reference review retrieved from https://pubmed.ncbi.nlm.nih.gov/19377391/ titled, The use of medical orders in acute care oxygen therapy, dated 2009, the professional reference review indicated, . Oxygen is considered to be a drug requiring a medical prescription and is subject to any law that covers its use and prescription . authorized by a physician following legal written instruction to a qualified nurse .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility's Pharmacy Consultant (PC) failed to identify irregularities and make recommendations for two of two sampled residents (Resident 4 and Resident 16) when: 1. Resident 4 was administered quetiapine (medication used to treat mental health disorders, including schizophrenia, bipolar disorder, and depression) with no clinical justification for use, no monitoring of labs (thyroid function labs) without receiving a baseline eye exam. 2. Resident 16's received Aripiprazole (a antipsychotic medication that works in the brain to treat schizophrenia, bipolar disorder, depression and autism spectrum disorders) without two Gradual Dose Reductions (GDR tapering of a dose to determine if symptoms conditions or risks can be managed by a lower dose or if the medication can be discontinued) in a year, without a yearly eye exam, without adequately monitoring labs (no baseline lipids) and medication was increased inappropriately. These failures had the potential to result in the residents increased risk for adverse effects as follows but not limited to, hyperlipidemia (abnormally high concentration or fats or lipids in the blood), hyperglycemia (high blood sugar) and movement disorders, slow metabolism, vision changes and death. Findings: 1. During a review of the facility's document admission Record (AR), dated 11/17/22, the AR indicated Resident 4's admission date at the facility was 7/25/2018. The AR indicated Resident 4 had the diagnosis of unspecified dementia, mild with other behavioral disturbance onset date of 7/25/2018 and unspecified psychosis (a severe mental disorder in which thoughts and emotions are so impaired that contact is lost with external reality) not due to a substance or known physiological condition onset date of 7/30/2019. During a review of the facility's document Order Summary Report (OSR), dated 11/17/22, the OSR indicated Resident 4 had been taking Quetiapine since her admission on [DATE]. The OSR indicated Resident 4 was currently receiving Quetiapine 50 MG give 1 tablet two times a day for psychosis manifested by: agitation, aggression, crying, hallucination ordered on 5/09/22. During an interview on 11/17/22, at 2:11 p.m., with Licensed Vocational Nurse (LVN) 2, LVN 2 stated, Resident 4 had a history of thinking her belongings were being stolen and verbal aggression. LVN 2 stated, Resident 4 was not physically aggressive. LVN 2 stated, that she had not witnessed Resident 4 hallucinating. During a concurrent interview and record review on 11/17/22, at 2:29 p.m., with LVN 2, the OSR, dated 11/17/22 was reviewed. LVN 2 stated, Resident 4 had no orders to check thyroid (a gland in the neck which secretes hormones regulating growth and development through the rate of metabolism) function. LVN 2 stated, she could not find any record of thyroid function labs being completed for Resident 4. LVN 2 stated, she did not know why it was important to check thyroid levels for residents on Quetiapine. During an interview on 11/17/22, at 2:30 p.m., with the Minimum Data Set Nurse (MDS), the MDS stated, Resident 4 should have had thyroid levels checked. The MDS stated, Quetiapine can change thyroid functioning. The MDS stated, if Resident 4's thyroid levels were not there was a potential for Resident 4 to feel cold and clammy, be sluggish, have hot flashes or have nails or hair that become brittle. During an interview on 11/17/22, at 3:27 p.m., with the Contracted Pharmacist (CP), the CP stated, according to the drug manufacturer Quetiapine usage for psychosis was not indicated for long term use. The CP stated, there was an increased risk for death in elderly people who have psychosis and are taking Quetiapine. The CP stated he did not make recommendations for Resident 4 to have an eye exam or thyroid levels checked. The CP stated Resident 4 should have had thyroid function monitoring. The CP stated there was a potential for Quetiapine to slow metabolism (the chemical processes that occur within a living organism in order to maintain life), cause weight gain and intolerance to cold. The CP stated, Resident 4 should have had a baseline eye exam and eye exams every 6 months. The CP stated, Quetiapine could affect Resident 4's vision. The CP stated potentially if yearly eye exams were not done Resident 4's decline in vision to go unnoticed. During a review of the facility's document Ophthalmology Chart Note, dated 4/13/22, the Ophthalmology Chart Note indicated Resident 4 had an eye exam. Resident 4 had another eye exam on 10/19/22. The facility had no documented evidence an eye exam was conducted prior to starting Quetiapine on 7/25/2018. During an interview on 11/17/22, at 4:17 p.m., with the Director of Nursing (DON), The DON stated, it was important to monitor resident 4's thyroid levels while on Quetiapine. The DON stated, there was a potential for thyroid levels to change and affect the resident. the DON, stated if the thyroid was affected by Quetiapine there was a potential for Resident 4's metabolism to slow down, to become nervous or become agitated. During a concurrent interview and record review on 11/17/22, at 4:31 p.m., with the DON, [insurance provider] ANNUAL WELNESS EXAM, dated 6/15/2017 was reviewed. The DON stated, Resident 4 was admitted to the facility from home. The DON stated, that the medical history Resident 4 came to the facility with was from the [insurance provider] ANNUAL WELNESS EXAM The DON stated, Resident 4 did not have a diagnosis of psychosis prior to admission to the facility. The DON stated she did not know where Resident 4's diagnosis of psychosis came from. During a review of Lexicomp, a nationally recognized drug reference, the manufacturer for Quetiapine stated, . ALERT: US Boxed Warning . Increased mortality in elderly patients with dementia-related psychosis . Agitation/Aggression and psychosis associated with dementia . Note: For short-term adjunctive use while addressing underlying cause(s) of severe symptoms . quetiapine may be considered for the treatment of agitation and psychosis in certain patients; however . use should be limited to patients whose symptoms are dangerous, severe, or cause significant patient distress due to safety risks associated with antipsychotic use . Frequency of Antipsychotic Monitoring . Monitoring Parameters . [thyroid function labs] frequency of monitoring . Annually . Advance Practitioners Physical Assessment/Monitoring . Obtain lens exam at start of therapy and then every 6 months . During a review of the facility's policy and procedure (P&P) titled, Antipsychotic Medication Use, dated 12/2016, the P&P indicated, . Antipsychotic medications will be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reduction and re-review . Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective . The Attending Physician will identify, evaluate and document . symptoms that may warrant the use of antipsychotic medications . Diagnoses alone do not warrant the use of antipsychotic medication . antipsychotic medications will generally only be considered if the following conditions are also met: . The behavioral symptoms present a danger to the resident or others . During a review of the facility's P&P titled, Consultant Pharmacist Services Provider Requirements dated 2007, the P&P indicated, . The consultant pharmacist agrees to render required service in accordance with . regulations and guidelines; nursing care center policies and procedures; . professional standards . The consultant pharmacist . provides pharmaceutical care services, including the following . Communicate to the responsible prescriber, the facility's medical director and the director of nursing potential or actual problems detected and other findings related to medication therapy orders at least monthly. Communicate recommendations for changes in medication and the monitoring of medication therapy . 2. During a review of the facility's document admission RECORD (AR), dated 11/17/22, the AR indicated Resident 16's admission date at the facility was 2/27/2019. The AR indicated Resident 16 had the diagnosis of unspecified dementia (a disorder marked by memory disorders, personality changes and impaired reasoning) unspecified severity, without behavioral disturbance, psychotic (loss of reality) disturbance and anxiety with onset date of 2/27/2019 and schizoaffective disorder (a mental health condition including schizophrenia and mood disorder symptoms), unspecified onset date of 2/27/2019. During a review of the facility's document ORDER SUMMARY REPORT (OSR), dated 11/18/22, the OSR indicated Resident 16 had one GDR attempted in a year. Resident 16 had an order for Aripiprazole 5 milligram (MG) Give 1 tablet by mouth one time a day related to Unspecified Dementia without Behavioral Disturbance for 30 days, started on 10/9/21 with an end date of 11/8/21. Resident 16 had an order for Aripiprazole to be increased to 10 MG Give 1 tablet by mouth one time a day started on 11/9/21. During a concurrent interview and record review on 11/16/22, at 2:19 p.m., with Licensed Vocational Nurse (LVN) 2, Resident 16's BEHAVIORAL MONITORING RECORD (BMR), dated 9/2021 through 9/2022 was reviewed. The BMR indicated Resident 16 was being monitored for the behaviors of psychosis: visual hallucinations of lights and ghosts for use of Aripiprazole. LVN 2 verified Resident 16 had 31 behaviors documented for the month of 9/2021, 13 behaviors documented for the month of 10/2021, six behaviors documented for the month of 11/2021, 9 behaviors documented for the month of 12/2021, 42 behaviors documented for the month of 1/2022, 10 behaviors documented for the month of 2/2022, 26 behaviors documented for the month of 3/2022, 45 behaviors documented for the month of 4/2022, zero behaviors documented for the month of 8/2022, zero behaviors documented for the month of 9/2022 and 19 behaviors documented for the month of 10/2022. LVN 2 stated, Resident 16's hallucinations presented as the resident thought the television was talking to him and would talk back to the television. LVN 2 stated Resident 16 was not violent or aggressive. LVN 2 stated, Resident 16's order for Aripiprazole 5 MG, dated 10/9/21 was automatically increased from 5 MG to 10 MG after 1 month on 11/9/21. LVN 2 stated, Resident 16 had 13 behaviors in the month of 10/2021 and 6 behaviors in the month of 11/2021. LVN stated, she did not know why Resident 16's Aripiprazole was automatically increased from 5 MG to 10 MG. LVN 2 stated, the Aripiprazole was increased without an increase in resident 16's behaviors. LVN 2 stated, there was a potential for the resident to have higher risk of side effects if he received more Aripiprazole than he needed. LVN 2 stated, there was a potential for Resident 16 to develop hyperlipidemia (an abnormally high concentration of fats or lipid in the blood), hyperglycemia (an excess of glucose in the bloodstream) and tardive dyskinesia (a disorder characterized by involuntary movements of the face and jaw) while taking Aripiprazole. LVN 2 stated, the goal should be for Resident 16 to be on the lowest dose of Aripiprazole to treat behaviors. During a review of Progress Notes, dated 7/4/22, the Progress Notes indicated, [Facility's physician] was called regarding GDR. Resident has had 1 episode noted this past month of behaviors. [Facility's physician] gave [telephone order] to keep medication at current dose and continue to monitor. During a review of the facility's document [Contracted pharmacy] NURSING RECOMMENDATIONS includes the following Classifications: [Medication Regimen Review], dated 10/1/22 [through] 10/31/22, the [Contracted pharmacy] NURSING RECOMMENDATIONS includes the following Classifications: [Medication Regimen Review] indicated, . [Resident 16] . has been taking the antipsychotic Aripiprazole since 11/9/21. Please evaluate and consider a dose reduction. The document indicated no GDR was attempted. During a review of Progress Notes, dated 10/3/22, the Progress Notes indicated, . notified [facility's physician] via telephone of possible GDR attempt for medication Aripiprazole. [Facility's physician] gave [telephone order] to continue with current medication regimen, [no] new orders at this time. During a concurrent interview and record review on 11/16/22, at 2:58 p.m., with the Minimum Date Set Nurse (MDS), the facility's document, EYE EXAMINATIONS, dated 9/21/21 was reviewed. The EYE EXAMINATIONS indicated Resident 16 had an eye exam completed. The MDS stated, he was unable to find any other eye exam being completed for Resident 16. The MDS stated, Resident 16 should have had an eye exam every year while taking Aripiprazole. The MDS stated, there was a potential for Resident 16's vision to decline while taking Aripiprazole. The MDS stated, baseline lipids (a blood test to cholesterol and other fats done prior to the start of a treatment) should have been done prior to Resident 16 stating on Aripiprazole. The MDS stated, Aripiprazole had the potential to alter lipid levels. The MDS stated if lipids were too high there was a potential for stroke (something blocks blood supply to part of the brain or when a blood vessel in the brain bursts) or heart attack (sudden and sometimes fatal occurrence resulting in the death of part of the heart muscle). During an interview on 11/17/22, at 3:53 p.m. with the Contracted Pharmacist (CP), the CP stated, he did not make any recommendations for Resident 16 to have an eye exam. The CP stated, it was important for Resident 16 to receive yearly eye exams because the Aripiprazole had the potential to affect the eyes. The CP stated, Resident 16 should have had a baseline lipid level done prior to starting on Aripiprazole. The CP stated, raised lipid levels would be an indication that the medication contributed to the value. The CP stated, if the medication was negatively contributing to lipid values, then a determination could be made on whether the medication benefits were worth the risk of the medication. The CP could not provide an indication for Resident 16's Aripiprazole being automatically increased from 5 MG to 10 MG. The CP stated, the goal for Resident 16 should have been for him to be on the lowest effective dose to treat symptoms. The CP stated, there was a potential for hyperlipidemia (abnormally high concentration or fats or lipids in the blood), hyperglycemia (high blood sugar) and movement disorders if Resident 16 received a higher than needed dose of Aripiprazole. The CP stated, he did not make recommendations for Resident 16 to have an eye exam. The CP stated, Resident 16 should have had a baseline eye exam done. The CP stated, there was a potential for cataracts to go undetected if Aripiprazole was contributing and Resident was not receiving eye exams. During an interview on 11/17/22, at 4:18 p.m., with the Director of Nursing (DON), the DON stated, Resident 16's Aripiprazole dose should have not been increased automatically without an indication. The DON stated, the Resident 16 should have had his behavior assessed and if the behaviors were not controlled then non-pharmacological interventions should have been attempted prior to increasing the dose. The DON stated, the nurse who received the order should have clarified it with the doctor. The DON stated, if the doctor declines a GDR there should be a clinical justification documentation of evidence why it should not be attempted. The DON stated, Resident 16 should have had a baseline lipid level checked prior to being administered Aripiprazole. The DON stated, it was important to check lipids because Aripiprazole can affect the kidneys. The DON stated, Resident 16 should have had an eye exam done at baseline and yearly while taking Aripiprazole. The DON stated, there was a potential for the medication to cause a decrease in vision. During a review of the facility's policy and procedure (P&P) titled, Medication Regimen Review and Reporting, dated 2007, the P&P indicated, Medication Regimen Review (MRR) is defined as the systematic evaluation of medication therapy . The consultant pharmacist and the nursing care center follows up on recommendations to verify that appropriate action has been taken . Physician may accept and act on a recommendation or reject a recommendation and provide an explanation for disagreement in the resident's medical record . If there is potential for serious harm and the attending physician does not concur, or refuses to document an explanation, the director of nursing and the consultant pharmacist contact the medical director. If the attending physician is also the medical director, a meeting shall be arranged to discuss issues and come to an agreement in order to ensure that no actual harm occurs . During a review of the facility's policy and procedure (P&P) titled, Antipsychotic Medication Use, dated 12/2016, the P&P indicated, . Antipsychotic medications will be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reduction and re-review . Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective . The Attending Physician will identify, evaluate and document . symptoms that may warrant the use of antipsychotic medications . Diagnoses alone do not warrant the use of antipsychotic medication . antipsychotic medications will generally only be considered if the following conditions are also met: . The behavioral symptoms present a danger to the resident or others . During a review of the facility's P&P titled, Consultant Pharmacist Services Provider Requirements dated 2007, the P&P indicated, . The consultant pharmacist agrees to render required service in accordance with . regulations and guidelines; nursing care center policies and procedures; . professional standards . The consultant pharmacist . provides pharmaceutical care services, including the following . Communicate to the responsible prescriber, the facility's medical director and the director of nursing potential or actual problems detected and other findings related to medication therapy orders at least monthly. Communicate recommendations for changes in medication and the monitoring of medication therapy . During a review of Lexicomp, a nationally recognized drug reference, the manufacturer for aripiprazole stated, . ALERT : US Boxed Warning . Increased mortality in elderly patients with dementia-related psychosis: Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk for death. Aripiprazole is not approved for the treatment of patients with dementia-related psychosis . Use: Labeled Indications . Bipolar disorder . Irritability associated with autistic disorder . Major Depressive disorder . Schizophrenia . Tourette disorder . Warning/Caution: Even though it may be rare, some people may have very bad and sometimes deadly side effects . get medical help right away if you have the following signs or symptoms . Vision changes . Blurred vision . Advance Practitioners Physical Assessment/ Monitoring . Obtain fasting lipids . Obtain ophthalmic exam .

**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 unnecessary psychotropic drugs (drugs that affect brain activities associated with mental processes and behavior) for two of four residents (Resident 4 and Resident 16) when: 1. Resident 4 received Quetiapine (an antipsychotic medication) without a consistent indication (define) and clinical justification for use, without adequate lab monitoring (no thyroid function labs done) and Resident 4 did not receive a baseline eye exam prior to being started on the medication. 2. Resident 16's received Aripiprazole (a antipsychotic medication that works in the brain to treat schizophrenia, bipolar disorder, depression and autism spectrum disorders) without two Gradual Dose Reductions (GDR tapering of a dose to determine if symptoms conditions or risks can be managed by a lower dose or if the medication can be discontinued) in a year, without a yearly eye exam, without adequately monitoring labs (no baseline lipids) and medication was increased inappropriately. These failures had the potential to result in the residents increased risk for adverse effects as follows but not limited to, hyperlipidemia (abnormally high concentration or fats or lipids in the blood), hyperglycemia (high blood sugar) and movement disorders, slow metabolism, vision changes and death. Findings: 1. During a review of the facility's document admission Report (AR), dated 11/17/22, the AR indicated Resident 4's admission date at the facility was 7/25/2018. The AR indicated Resident 4 had the diagnosis of unspecified dementia, mild with other behavioral disturbance onset date of 7/25/2018 and unspecified psychosis (a severe mental disorder in which thoughts and emotions are so impaired that contact is lost with external reality) not due to a substance or known physiological condition onset date of 7/30/2019. During a review of the facility's document Order Summary Report (OSR), dated 11/17/22, the OSR indicated Resident 4 was currently receiving Quetiapine 50 milligram (MG) give 1 tablet two times a day for psychosis manifested by: agitation, aggression, crying, hallucination ordered on 5/09/22. The OSR indicated Resident 4 had been taking Quetiapine since her admission on [DATE]. During an interview on 11/17/22, at 2:11 p.m., with Licensed Vocational Nurse (LVN) 2, LVN 2 stated, Resident 4 had a history of thinking her belongings were being stolen and verbal aggression. LVN 2 stated, Resident 4 was not physically aggressive. LVN 2 stated, that she had not witnessed Resident 4 hallucinating. During a concurrent interview and record review on 11/17/22, at 2:29 p.m., with LVN 2, the OSR, dated 11/17/22 was reviewed. LVN 2 stated Resident 4 had no orders to check thyroid (a gland in the neck which secretes hormones regulating growth and development through the rate of metabolism) function. LVN 2 stated, she could not find any record of thyroid function labs being completed for Resident 4. LVN 2 stated, she did not know why it was important to check thyroid levels for residents on Quetiapine. During an interview on 11/17/22, at 2:30 p.m., with the Minimum Data Set Nurse (MDS), the MDS stated, that Resident 4 should have had thyroid levels checked. The MDS stated, Quetiapine can change thyroid functioning. The MDS stated, if Resident 4's thyroid levels were not there was a potential for Resident 4 to feel cold and clammy, be sluggish, have hot flashes or have nails or hair that become brittle. During an interview on 11/17/22, at 3:27 p.m., with the Contracted Pharmacist (CP), the CP stated, according to the drug manufacturer Quetiapine usage for psychosis was not indicated for long term use. The CP stated, there was an increased risk for death in elderly people who have psychosis and are taking Quetiapine. The CP stated, Resident 4 should have had thyroid function monitoring. The CP stated, there was a potential for Quetiapine to slow metabolism(the chemical processes that occur within a living organism in order to maintain life), cause weight gain and intolerance to cold. The CP stated, Resident 4 should have had a baseline eye exam and eye exams every 6 months. The CP stated, Quetiapine could affect Resident 4's vision. The CP stated, potentially if yearly eye exams were not done Resident 4's decline in vision to go unnoticed. During a review of the facility's document Ophthalmology Chart Note, dated 4/13/22, the Ophthalmology Chart Note indicated Resident 4 had an eye exam. Resident 4 had another eye exam on 10/19/22. The facility had no documented evidence an eye exam was conducted prior to starting Quetiapine on 7/25/2018. During an interview on 11/17/22, at 4:17 p.m., with the Director of Nursing (DON), the DON, stated it was important to monitor resident 4's thyroid levels while on Quetiapine. The DON stated, there was a potential for thyroid levels to change and affect the resident. The DON stated, if the thyroid was affected by Quetiapine there was a potential for Resident 4's metabolism (the chemical process that occur within a living organism in order to maintain life) to slow down, to become nervous or become agitated. During a concurrent interview and record review on 11/17/22, at 4:31 p.m., with the DON, [insurance provider] ANNUAL WELNESS EXAM, dated 6/15/2017 was reviewed. The DON stated, Resident 4 was admitted to the facility from home. The DON stated, that the medical history Resident 4 came to the facility with was from the [insurance provider] ANNUAL WELNESS EXAM The DON stated, Resident 4 did not have a diagnosis of psychosis prior to admission to the facility. The DON stated, she did not know where Resident 4's diagnosis of psychosis came from. During a review of Lexicomp, a nationally recognized drug reference, the manufacturer for Quetiapine stated, . ALERT: US Boxed Warning . Increased mortality in elderly patients with dementia-related psychosis . Agitation/Aggression and psychosis associated with dementia . Note: For short-term adjunctive use while addressing underlying cause(s) of severe symptoms . quetiapine may be considered for the treatment of agitation and psychosis in certain patients; however . use should be limited to patients whose symptoms are dangerous, severe, or cause significant patient distress due to safety risks associated with antipsychotic use . Frequency of Antipsychotic Monitoring . Monitoring Parameters . [thyroid function labs] frequency of monitoring . Annually . Advance Practitioners Physical Assessment/Monitoring . Obtain lens exam at start of therapy and then every 6 months . During a review of the facility's policy and procedure (P&P) titled, Antipsychotic Medication Use, dated 12/2016, the P&P indicated, . Antipsychotic medications will be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reduction and re-review . Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective . The Attending Physician will identify, evaluate and document . symptoms that may warrant the use of antipsychotic medications . Diagnoses alone do not warrant the use of antipsychotic medication . antipsychotic medications will generally only be considered if the following conditions are also met: . The behavioral symptoms present a danger to the resident or others . 2. During a review of the facility's document admission RECORD (AR), dated 11/17/22, the AR indicated Resident 16's admission date at the facility was 2/27/2019. The AR indicated Resident 16 had the diagnosis of unspecified dementia (a disorder marked by memory disorders, personality changes and impaired reasoning) unspecified severity, without behavioral disturbance, psychotic (loss of reality) disturbance and anxiety with onset date of 2/27/2019 and schizoaffective disorder (a mental health condition including schizophrenia and mood disorder symptoms), unspecified onset date of 2/27/2019. During a review of the facility's document ORDER SUMMARY REPORT (OSR), dated 11/18/22, the OSR indicated Resident 16 had one GDR attempted in a year. Resident 16 had an order for Aripiprazole 5 milligram (MG) Give 1 tablet by mouth one time a day related to Unspecified Dementia without Behavioral Disturbance for 30 days, started on 10/9/21 with an end date of 11/8/21. Resident 16 had an order for Aripiprazole to be increased to 10 MG Give 1 tablet by mouth one time a day started on 11/9/21. During a concurrent interview and record review on 11/16/22, at 2:19 p.m., with Licensed Vocational Nurse (LVN) 2, Resident 16's BEHAVIORAL MONITORING RECORD (BMR), dated 9/2021 through 9/2022 was reviewed. The BMR indicated Resident 16 was being monitored for the behaviors of psychosis: visual hallucinations of lights and ghosts for use of Aripiprazole. LVN 2 verified Resident 16 had 31 behaviors documented for the month of 9/2021, 13 behaviors documented for the month of 10/2021, six behaviors documented for the month of 11/2021, 9 behaviors documented for the month of 12/2021, 42 behaviors documented for the month of 1/2022, 10 behaviors documented for the month of 2/2022, 26 behaviors documented for the month of 3/2022, 45 behaviors documented for the month of 4/2022, zero behaviors documented for the month of 8/2022, zero behaviors documented for the month of 9/2022 and 19 behaviors documented for the month of 10/2022. LVN 2 stated, Resident 16's hallucinations presented as the resident thought the television was talking to him and would talk back to the television. LVN 2 stated Resident 16 was not violent or aggressive. LVN 2 stated, Resident 16's order for Aripiprazole 5 MG, dated 10/9/21 was automatically increased from 5 MG to 10 MG after 1 month on 11/9/21. LVN 2 stated, Resident 16 had 13 behaviors in the month of 10/2021 and 6 behaviors in the month of 11/2021. LVN stated, she did not know why Resident 16's Aripiprazole was automatically increased from 5 MG to 10 MG. LVN 2 stated, the Aripiprazole was increased without an increase in resident 16's behaviors. LVN 2 stated, there was a potential for the resident to have higher risk of side effects if he received more Aripiprazole than he needed. LVN 2 stated, there was a potential for Resident 16 to develop hyperlipidemia (an abnormally high concentration of fats or lipid in the blood), hyperglycemia (an excess of glucose in the bloodstream) and tardive dyskinesia (a disorder characterized by involuntary movements of the face and jaw) while taking Aripiprazole. LVN 2 stated, the goal should be for Resident 16 to be on the lowest dose of Aripiprazole to treat behaviors. During a review of Progress Notes, dated 7/4/22, the Progress Notes indicated, [Facility's physician] was called regarding GDR. Resident has had 1 episode noted this past month of behaviors. [Facility's physician] gave [telephone order] to keep medication at current dose and continue to monitor. During a review of the facility's document [Contracted pharmacy] NURSING RECOMMENDATIONS includes the following Classifications: [Medication Regimen Review], dated 10/1/22 [through] 10/31/22, the [Contracted pharmacy] NURSING RECOMMENDATIONS includes the following Classifications: [Medication Regimen Review] indicated, . [Resident 16] . has been taking the antipsychotic Aripiprazole since 11/9/21. Please evaluate and consider a dose reduction. The document indicated no GDR was attempted. During a review of Progress Notes, dated 10/3/22, the Progress Notes indicated, . notified [facility's physician] via telephone of possible GDR attempt for medication Aripiprazole. [Facility's physician] gave [telephone order] to continue with current medication regimen, [no] new orders at this time. During an interview on 11/16/22, at 04:59 p.m., with the Minimum Data Set Nurse (MDS), the MDS stated, the pharmacist recommended a (GDR) for Resident 16 on 10/2022. The MDS stated, the doctor at the facility gave an order to continue with the current medication regimen. The MDS stated, there was no clinical justification for GDR not being done. The MDS stated, it was important to attempt a GDR because elderly residents could end up with long term effects from antipsychotics. The MDS stated, the potential long-term effects from antipsychotics could be extrapyramidal symptoms (involuntary movements that you cannot control), heart attack, or altered blood sugar levels. During a concurrent interview and record review on 11/16/22, at 2:58 p.m., with the MDS, the facility's document, EYE EXAMINATIONS, dated 9/21/21 was reviewed. The EYE EXAMINATIONS indicated Resident 16 had an eye exam completed. The MDS stated, he was unable to find any other eye exam being completed for Resident 16. The MDS stated, Resident 16 should have had an eye exam every year while taking Aripiprazole. The MDS stated, there was a potential for Resident 16's vision to decline while taking Aripiprazole. The MDS stated, baseline lipids (a blood test to cholesterol and other fats done prior to the start of a treatment) should have been done prior to Resident 16 starting on Aripiprazole. The MDS stated, Aripiprazole had the potential to alter lipid levels. The MDS stated if lipids were too high there was a potential for stroke (something blocks blood supply to part of the brain or when a blood vessel in the brain bursts) or heart attack (sudden and sometimes fatal occurrence resulting in the death of part of the heart muscle). During an interview on 11/17/22, at 3:53 p.m. with the Contracted Pharmacist (CP), the CP stated, he did not make any recommendations for Resident 16 to have an eye exam. The CP stated, it was important for Resident 16 to receive yearly eye exams because the Aripiprazole had the potential to affect the eyes. The CP stated, Resident 16 should have had a baseline lipid level done prior to starting on Aripiprazole. The CP stated, raised lipid levels would be an indication that the medication contributed to the value. The CP stated, if the medication was negatively contributing to lipid values, then a determination could be made on whether the medication benefits were worth the risk of the medication. The CP could not provide an indication for Resident 16's Aripiprazole being automatically increased from 5 MG to 10 MG. The CP stated, the goal for Resident 16 should have been for him to be on the lowest effective dose to treat symptoms. The CP stated, there was a potential for hyperlipidemia (abnormally high concentration or fats or lipids in the blood), hyperglycemia (high blood sugar) and movement disorders if Resident 16 received a higher than needed dose of Aripiprazole. The CP stated, he did not make recommendations for Resident 16 to have an eye exam. The CP stated, Resident 16 should have had a baseline eye exam done. The CP stated, there was a potential for cataracts to go undetected if Aripiprazole was contributing and Resident was not receiving eye exams. During an interview on 11/17/22, at 4:18 p.m., with the Director of Nursing (DON), the DON stated, Resident 16's Aripiprazole dose should have not been increased automatically without an indication. The DON stated, the Resident 16 should have had his behavior assessed and if the behaviors were not controlled then non-pharmacological interventions should have been attempted prior to increasing the dose. The DON stated, the nurse who received the order should have clarified it with the doctor. The DON stated, if the doctor declines a GDR there should be a clinical justification documentation of evidence why it should not be attempted. The DON stated, Resident 16 should have had a baseline lipid level checked prior to being administered Aripiprazole. The DON stated, it was important to check lipids because Aripiprazole can affect the kidneys. The DON stated, Resident 16 should have had an eye exam done at baseline and yearly while taking Aripiprazole. The DON stated, there was a potential for the medication to cause a decrease in vision. During a review of the facility's policy and procedure (P&P) titled, Medication Regimen Review and Reporting, dated 2007, the P&P indicated, Medication Regimen Review (MRR) is defined as the systematic evaluation of medication therapy . The consultant pharmacist and the nursing care center follows up on recommendations to verify that appropriate action has been taken . Physician may accept and act on a recommendation or reject a recommendation and provide an explanation for disagreement in the resident's medical record . If there is potential for serious harm and the attending physician does not concur, or refuses to document an explanation, the director of nursing and the consultant pharmacist contact the medical director. If the attending physician is also the medical director, a meeting shall be arranged to discuss issues and come to an agreement in order to ensure that no actual harm occurs . During a review of Lexicomp, a nationally recognized drug reference, the manufacturer for aripiprazole stated, . ALERT : US Boxed Warning . Increased mortality in elderly patients with dementia-related psychosis: Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk for death. Aripiprazole is not approved for the treatment of patients with dementia-related psychosis . Use: Labeled Indications . Bipolar disorder . Irritability associated with autistic disorder . Major Depressive disorder . Schizophrenia . Tourette disorder . Warning/Caution: Even though it may be rare, some people may have very bad and sometimes deadly side effects . get medical help right away if you have the following signs or symptoms . Vision changes . Blurred vision . Advance Practitioners Physical Assessment/ Monitoring . Obtain fasting lipids . Obtain ophthalmic exam . During a review of the facility's policy and procedure (P&P) titled, Antipsychotic Medication Use, dated 12/2016, the P&P indicated, . Antipsychotic medications will be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reduction and re-review . Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective . The Attending Physician will identify, evaluate and document . symptoms that may warrant the use of antipsychotic medications . Diagnoses alone do not warrant the use of antipsychotic medication . antipsychotic medications will generally only be considered if the following conditions are also met: . The behavioral symptoms present a danger to the resident or others .

Based on dietetic service observations, dietary staff interviews and dietary document reviews the facility failed to ensure that dietary staff safely and effectively carried out the functions of food and nutrition services when: 1. [NAME] 1, Dietary Aide 1 and Dietary Service Supervisor did not know the right location to check the dish machine sanitizer. This failure had the potential to cause foodborne illness (stomach illness acquired from ingesting contaminated food) for 28 out of 28 sampled residents who received foods from the kitchen. 2. Dietary Aide 1 did not know how to check the concentration on the dish machine. This failure had the potential to cause foodborne illness for 28 out of 28 sampled residents who received foods from the kitchen. 3. [NAME] 1 did not know how to calibrate the thermometer. This failure had the potential to cause foodborne illness for 28 out of 28 sampled residents who received foods from the kitchen. 4. [NAME] 1 and Dietary Aide 1 was unable to verbalize the standard of cooling down process. This failure had the potential to cause foodborne illness for 28 out of 28 sampled residents who received foods from the kitchen. 5. [NAME] 1 changed the lunch menu without a Registered Dietitian consult on Tuesday 11/15/22. This failure had the potential risk of compromised residents' nutrition status for 28 out of 28 sampled residents who received foods from the kitchen. (Cross referred 803) 6. [NAME] 1 substituted tortilla chips to shredded iceberg lettuce, for mechanical soft residents on Tuesday Beef Nacho lunch and did not maintain the nutrition food group. This failure had the potential risk of compromised residents' nutrition status for 12 out of 28 sampled residents who received mechanical soft diet from the kitchen. (Cross referred 803) 7. [NAME] 1 served regular textured lasagna, green bean, and hard crust garlic bread to mechanical soft diet residents on Wednesday lunch (11/16/2022). This failure had the potential risk of choking for 12 out of 28 sampled residents who received mechanicals soft diet from the kitchen. (Cross referred 805) These failures had the potential to cause foodborne illness (stomach illness acquired from ingesting contaminated food), to negatively impact the residents' nutritional status and further in a medically compromised residents who received foods from the kitchen. Findings: 1. During a concurrent observations and interviews on 11/16/22, at 10:26 AM, with [NAME] 1 (CK 1), Dietary Aide 1 (DA 1) and Registered Dietitian (RD), in dishwashing area. CK 1 was observed testing the chlorine sanitation level of the dish machine by dipping a chlorine test strip inside the dish machine liquid once the dish machine was done washing. DA 1 was observed performing the same procedure tested the chlorine sanitation level of the dish machine by dipping a chlorine test strip inside the dish machine liquid once the dish machine was done washing. RD stated, standard of practice and the appropriate location to test chlorine sanitation level for the dish machine was on clean plate not by dipping a chlorine test strip inside the dish machine liquid. During a phone interview on 11/18/22, at 9:17 AM, with Dietary Service Supervisor (DSS). DSS stated, she checked the dish machine chlorine sanitation level by dipping a chlorine test strip inside the dish machine liquid once the dish machine was done washing. During a review of the facility's policy and procedure (P&P) titled Chemical Level of Dishwasher , revised 11/2020, the P&P indicated, The Dishwasher needs to be checked daily to ensure that it is maintaining the correct PPM . Procedure: 1. The Food Service worker will check the PPM .after each meal TID (Three time per day) daily. The P&P did not indicate where to test chlorine sanitation ppm for the dish machine. 2. During a concurrent observation and interviews on 11/16/22, at 10:26 AM, with DA 1 and Registered Dietitian (RD), in dishwashing area. DA 1 was observed checking the chlorine sanitation level of the dish machine by dipping a chlorine test strip inside the dish machine liquid once the dish machine was done washing. DA 1 then compared the color of the chlorine test strip to the indicator colors of the chlorine test strip container. DA 1 stated, that the chlorine test strip color should be between 100 ppm (measured as parts per million) and 200 ppm. DA 1 stated, to be on the safe side the ppm needed to be closer to 200 ppm. RD stated, that the chlorine sanitizer manufacturer indicate for low temperature dish machine should be 50 - 100 ppm with chlorine test strip. RD explained if the concentration of the chlorine sanitizer too low, it would not sanitize the dishes properly. If the concentration of the chlorine sanitizer too high, the chlorine sanitizer would stay on clean dishes. During a phone interview on 11/18/22, at 9:17 AM, with Dietary Service Supervisor (DSS). DSS stated, the correct parts per million (ppm) for the dish machine was 50 -100 ppm. DSS validated the potential risk if ppm was too low it would not be an effective sanitation of the dishes and too high ppm could cause cross contamination make residents sick. During a review of the chlorine sanitizer manufacturer for dish machine provided by the facility, dated 2021, the chlorine sanitizer manufacturer for dish machine indicated, .low temperature warewashing machine, . Sanitizer into final rinse water at a concentration between 50 and 100 ppm available chlorine. 3. During an observation on 11/16/22, at 09:11 AM, with CK1. CK 1 was observed calibrating the thermometer. CK 1 got a cup of 16-ounce (oz, form of measurement) ice water. CK 1 put the thermometer into the ice water and the thermometer temperature dropped to 26 degrees Fahrenheit. CK 1 stated, she had done calibrate thermometer. Then CK 1 logged in the calibrate temperature log with yes which indicated she had completed calibrated the temperature on the day. During a phone interview on 11/18/22, at 09:17 AM, with DSS. DSS stated, if the thermometer does not reach 32 degrees Fahrenheit in ice water, dietary staff needs to adjust the thermometer calibration nut to reach 32 degrees Fahrenheit and then document in the calibrate temperature log with yes. The DSS stated, the potential risk for thermometers were not properly calibrated was the dietary staff would get wrong reading when checked the temperature of the foods, it would cause food born illness. During a review of the facility's policy and procedure (P&P) titled, Calibration of Food Thermometers in Cold Bath, revised 11/2020, the P&P indicated, .thermometer should read 32 degrees Fahrenheit, if to does NOT reach 32 degrees Fahrenheit then you need to adjust the nut to 32 degrees Fahrenheit. 4. During an interview on 11/16/22, at 11:02 AM, with CK 1 and Registered Dietitian (RD). CK 1 stated, she did not usually make tuna salad, chicken salad or potatoes salad which need cooling process. So, she could not properly explain the cool down process. During an interview on 11/16/22, at 11: 05 AM, with DA 1 and RD. DA 1 stated, when he prepared tuna salad, he took a can of tuna from the dry storage room; then mixed the tuna with Mayonnaise. After that, he put the tuna salad in an ice bath and stored the tuna salad in walk in refrigerator without taking a temperature. DA 1 stated, he checked the tuna salad temperature before he served to residents. DA 1 stated, the Tuna temperature needs to be at 40 degrees Fahrenheit or below 40 degrees Fahrenheit. DA 1 stated, he did not record the cooling down process time and temperature. The RD stated, DA 1 did not perform the appropriate steps for the cool down process. During a phone interview on 11/18/22, at 09:17 AM, with DSS. DSS stated, food must cool down to 70 degrees Fahrenheit within two hours then to 41 degrees Fahrenheit within four hours. DSS stated, the cool down process was not used regularly in the kitchen. So dietary staff were not familiar with the cool down process. During a review of the facility's policy and procedure (P&P) titled FOOD PREPARATION: SUBJECT: COOL DOWN, dated 2018, the P&P indicated, Food that is cooked and will not be used for immediate service will be cooled to appropriate temperature within the allotted time to prevent microbial growth. Procedures: 1. food .must be cooled according to standards. A cool down log will be maintained to ensure standard are met. 2. Food must be cooled to 70 degrees Fahrenheit within 2 hours and then to 41 degrees Fahrenheit within the next four hours . During a review of the Federal Food and Drug Administration (FDA) Food code 2017, Section 3-501.14 Cooling, Time/Temperature control for safety Food shall be cooled within 4 hours to 41-degree Fahrenheit or less if prepared from ingredients at ambient temperature, such as .canned tuna. 5. During an observation of the noon meal plating, on 11/15/22, at 11:35 PM, CK 1 served Beef Nachos to residents. During an interview on 11/16/22, at 12:43 PM, with CK 1 and Registered Dietitian (RD) in kitchen. CK 1 stated residents liked to have Taco Tuesday. CK 1 explained Taco Tuesday was a way to honor residents requests to have a Mexican menu on Tuesdays. So, she just changed 11/15/22 Tuesday lunch menu to Beef Nacho without consulting the RD. CK 1 stated, this was her usual practice she just changed Tuesdays menu to Taco Tuesday. The CK 1 stated she would inform the DSS of the substitution and the DSS would document on the Menu Substitution Form. The RD would put her approval initial on the Menu substitution Form when she returned to the facility after the menu had changed and was served to residents. CK 1 stated, she did not have recipe or Cooks Spreadsheet (the document used to guide dietary staff on food items, portions, and therapeutic diet) for Beef Nachos. RD stated, the Standard of practice was for DSS and dietary staff to consult her before they made any changes to the menu. RD stated, the CK 1 or the DSS needed to call the menu company to get a recipe and Cooks Spreadsheet before changing the menu. During a phone interview on 11/18/22, at 09: 17 AM, with DSS. DSS stated, it was very important Cooks followed the menu, recipe, and Cooks spreadsheet. DSS stated, the potential risks of not following the menu, recipe and Cooks spreadsheets was changing the nutritive values of the meals served; the taste of the served meals different without follow recipe and the residents did not getting the right serving portions. Residents would not receive the correct nutrition which had potential risk of compromised residents' nutrition status. During a review of the facility Job Description, titled, Dietary Cook/Cook, Worker , undated, the Job Description indicated, .Essential Job Functions: .Follow . recipes .follow .therapeutic menus . 6. During a concurrent dining observation and interview on 11/15/22, at 12:20 PM, with Resident 15 in Resident 15's room. Resident 15 received ground meat, nacho cheese, shredded iceberg lettuce on her entrée. Resident 15 complained she did not get tortilla chips. During an interview on 11/16/22, at 12:43 PM, with CK 1 and Registered Dietitian (RD) in kitchen. CK 1 stated, she substituted tortilla chips to shredded iceberg lettuce on 11/15/22 for lunch for mechanical soft residents. RD stated, it was inappropriate for the substitution. RD stated, CK 1 needed to substitute tortilla chips for soft tortilla for mechanical soft residents. RD unable provided dietary staff in service for food substitution. During a phone interview on 11/8/22, at 9:17 AM, with DSS. DSS stated, it was unacceptable exchange a carbohydrate, tortilla chips, to a vegetable, shredded iceberg lettuce for mechanical soft diet because the nutrition value was compromised. During a review of the facility Job Description, titled, Dietary Cook/Cook, Worker , undated, the Job Description indicated, .Essential Job Functions: .Follow . recipes .follow .therapeutic menus . 7. During an observation of the noon meal plating, on 11/16/22, at 11:43 AM. CK 1 served same regular diet lasagna, green beans, and garlic bread as entrée to all residents including the residents on mechanical soft diet. During a concurrent observation and interview on 11/16/22, at 12:36 PM, with Registered Dietician (RD). Test tray for mechanical soft diet was performed. RD stated, the texture for mechanical soft diet was not appropriate. RD stated, served lasagna and green beans should be chopped up and the garlic bread crust was too hard for mechanical soft residents. During a phone interview on 11/18/22, at 09:17 AM, with DSS. DSS stated Residents who are on a mechanical soft diet should receive chopped up lasagna, green beans, and garlic bread without hard crust. DSS further stated, it was unacceptable for residents who were on mechanical soft diets to receive a regular diet which had high potential risk of choking. DSS claimed CK 1 too depended on her providing guideline on mechanical soft diet. DSS was sick and not in the facility for this week. DSS stated CK 1 dropped the ball. During a review of the facility Job Description, titled, Dietary Cook/Cook, Worker , undated, the Job Description indicated, .Essential Job Functions: .follow .therapeutic menus .

Based on dietary observations, dietary staff interviews and record reviews, the facility failed to ensure menus were followed and the nutritional needs of the residents were met when; 1. [NAME] 1 changed Tuesdays lunch menu without the consultation of the Registered Dietitian for 28 out of 28 sampled residents. This failure had the potential to compromise the nutrition status for 28 out of 28 sampled residents who received foods from the kitchen. (Cross referred 802) 2. [NAME] 1 did not substitute the equivalent nutritional food group, for lunch on 11/15/22 when beef nachos were served for 12 out of 28 sampled residents (Resident 1, 3, 6, 8, 9, 11, 13,15,17,18,19, 21) who received mechanicals soft diets. (Cross referred 802) These failures had the potential to negatively impact the residents' nutritional status and further compromising resident's medical status. Findings: 1. During an observation of the noon meal plating, on 11/15/22, at 11:35 PM, [NAME] 1 (CK 1) served beef nachos for residents. CK 1 put tortilla chips, nacho cheese, shredded iceberg lettuce, and ground beef as an entree. During an interview on 11/16/22, at 12:43 PM, with CK 1 and Registered Dietitian (RD) in kitchen. CK 1 stated, residents would like to have taco tuesday. CK 1 explained taco tuesday was a way honoring residents request to have Mexican food. CK 1 stated, she changed the lunch menu to beef nacho on 11/15/22 without consulting the RD. CK 1 stated, this was her usual practice to change Tuesdays menu to Taco Tuesday and later inform Dietary Services Supervisor (DSS). Then DSS would later document on menu substitution form. The RD would put her approval initial on the menu substitution form when she was back to facility after the menu had been changed and served to residents. CK 1 stated, she did not have recipe or cooks spreadsheet (the document used to guide dietary staff on food items, portions, and therapeutic diet) for beef nachos. The RD stated, the standard of practice was for DSS and dietary staff to consult and get approval before any menu changes or food substitution occur. RD stated, she or DSS needed to call the menu company to get recipes and cook spreadsheets for the dietary staff. During a phone interview on 11/18/22, at 09:17 AM, with DSS. DSS stated, it was very important to follow the menu, recipes, and cooks spreadsheets. DSS stated, the potential risks for not following the menu, recipes and cooks spreadsheets was changing the nutrition values of the meals served; the taste of themeals served and the residents not being served the correct portions. Residents would not receive the the correct nutrition which had potential risk of compromising residents' nutrition status. DSS acknowledged she needed to get approval from RD before changing the menu. During a review of the facility's policy and procedure (P&P), titled Menu Planning and Approval, revised 11/2020, the P&P indicated, POLICY: .The Registered Dietitian shall approve the menu. PROCEDURE: .2. The Registered Dietitian makes seasonal changes and/or modifications.5. The Registered Dietitian plans all menus. During a review of the facility's Menu Substitution Form, undated, the Menu Substitution Form indicated, 5/24/22 Scheduled Food item: Spaghetti and meat ball, garlic bread and salad substituted with Chicken Nachos; 5/31/22 Scheduled Food item Chicken Alfredo, Angel Hair Pasta, garlic bread, substituted with Beef Tacos, lettuce, tomatoes; 6/7/22: Scheduled Food item Roasted Turkey, carrot, stuffing , substituted with: Enchiladas, rice and bean; 6/14/22: Scheduled Food item BBQ Chicken, baked beans, coleslaw , substituted with Taco, rice, bean, lettuce and tomatoes; 6/21/22: Scheduled Food item Spaghettis, meat ball, garlic bread, substituted with Beef Nacho, rice, bean; 6/28/22: Scheduled Food item Chicken Alfredo, substituted with Cheese Enchiladas, rice and bean; 7/5/22: Scheduled Food item Roasted Turkey, substituted with Mario's Traditional Mexican Feast; all of the reason substitution those menu were for Taco Tuesday, and DSS initial all substitution menu and RD review , approval those substitution. 2. During a concurrent dining observation and interview on 11/15/22, at 12:20 PM, with Resident 15 in Resident 15's room. Resident 15 received ground meat, Nacho cheese, shredded iceberg lettuce on her entrée. Resident 15 complained she did not get tortilla chips. During an interview on 11/16/22, at 12:43 PM, with [NAME] 1 (CK 1) and Registered Dietitian (RD) in kitchen. CK 1 stated, she substituted tortilla chips for shredded iceberg lettuce on 11/15/22 lunch beef nachos for mechanical soft residents. CK 1 stated, she did not have a beef nacho recipe or cooks spreadsheet (the document used to guide dietary staff on food items, portions, and therapeutic diet) for beef nachos. RD stated, it was inappropriate to substitute tortilla chips for shredded iceberg lettuce. RD validated, CK 1 needed substitute tortilla chips to soft tortillas for mechanical soft residents. RD stated, dietary staff needed to get approval before make substitutions. RD stated, she did not get call, text from dietary staff regarding this approved substitution. RD was unable provided an inservice for dietary staff regarding the substitution of food items . During a phone interview on 11/8/22, at 09:17 AM, with DSS. DSS stated, it was unacceptable to exchange carbohydrate food group from tortilla chips with a vegetable food group to shredded iceberg lettuce for mechanical soft diets. DSS stated, the potential risk of substituting inappropriate food groups would compromise the nutrition value. During a review of the Resident 15's physician diet ordered, dated 11/16/22, the physician diet order indicated, Diet: Fortified diet (diet with added extra nutrients to increase the calories and/or protein density to promote improvement in residents nutrition status), Mechanical Soft texture (food texture that requires a reduced amount of chewing), . During a review of the facility's provided physician diet orders, dated 11/16/22, the physician diet orders indicated, 12 Residents (Resident 1, 3, 6, 8, 9, 11, 13, 15, 17, 18, 19, 21) on mechanical soft diet. During a review of the regulation F 813: § 483.60 (C) Menus and nutritional adequacy, the F 813 indicates, Menus must - . (6) Be reviewed by the facility's dietitian .for nutritional adequacy . During a review of the facility's policy and procedure (P&P) titled, Menu Substitution , revised 11/2020, the (P&P) indicated, .3. An appropriate substitution is made .

Based on dietary observations, interviews, and record review, the facility failed to ensure the appropriate food textures were provided when 12 (Resident 1, 3, 6, 8, 9, 11, 13, 15, 17, 18, 19, 21) out of 12 sampled residents who have a physician order to receive a mechanical soft diet (a diet with food texture need to chop up or ground into small piece for residents who have limited chewing and swallowing ability) received a regular textured diet for lunch on 11/16/ 2022. This failure had the potential to place the residents at risk of choking for Resident 1, 3, 6, 8, 9, 11, 13, 15, 17, 18, 19, 21. (Cross reference 801, 802) Findings: During an observation of the noon meal plating, on 11/16/22, at 11:43 AM, the steam table had 2 food items, one of the food items was regular textured lasagna and regular textured green beans. [NAME] 1 (CK 1) served lasagna, green beans, and garlic bread as entrée to all residents including the residents on mechanical soft diets. During a concurrent observation and interview on 11/16/22, at 12:36 PM, with Registered Dietitian (RD). A test tray for mechanical soft diet was performed. RD stated, the texture for mechanical soft diet was not appropriate. RD stated, the lasagna and green beans should have been chopped up and the garlic bread crust was too hard for mechanical soft residents. During a phone interview on 11/18/22, at 09:17 AM, with Dietary Service Supervisor (DSS). DSS stated, CK depended on her provided guidance regarding mechanical soft diet. DSS was not in the facility this week because she was sick. DSS stated, CK 1 dropped the ball. DSS stated, residents who are ordered a mechanical soft diet should have received chopped up lasagna, green beans, and garlic bread without hard crust. DSS stated, it was unacceptable for residents who have physician orders for mechanical soft diets to receive a regular diet which increased the residents risk for choking . During a review of the facility's provided physician diet orders, dated 11/16/22, the physician diet orders indicated, 12 Residents (Resident 1, 3, 6, 8, 9, 11, 13, 15, 17, 18, 19, 21) on mechanical soft diet. During a review of the Cooks Spreadsheet (the document used to guide dietary staff on food items, portions, and therapeutic diet), dated 11/16/22, the Cooks Spreadsheet indicated .Mechanical soft: Lasagna need to be ground, [NAME] bean need to be chopped . During a review of the facility provided Mechanical Soft/(ground) diet definition from diet menu, undated, the diet menu indicated, MECHANICAL SOFT (Ground). Intended Use: To provide a nutritionally adequate diet that requires a reduced amount of mastication. Normally this order is for residents who have limited chewing ability and intact swallowing ability.Recommendations: . Some cooked vegetable may need to be chopped.

Based on observation, interview, and record review, the facility failed to ensure resident food preferences were honored for one of 28 sampled residents (Resident 26) when green beans were placed and served on Resident 26's lunch plate. This failure had the potential to result in decreased food intake, and could result in unplanned weight loss, further compromising Resident 26's nutritional and medical status. Findings: During an observation of the noon meal plating, on 11/16/22, at 11:43 AM, the steam table had two food items lasagna and green beans. [NAME] 1 (CK 1) served lasagna, green beans, and garlic bread as entrée to all residents. During a concurrent observation and interview on 11/16/22, at 12:21 PM, with Resident 26. Resident 26 received lasagna, green beans, and garlic bread on her entrée plate. Resident 26 complained she did not want green beans. During an interview on 11/16/22, at 02:48 PM, with the Registered Dietitian (RD). The RD stated, food preference updated upon admission, quarterly, annually, and as needed. The RD notified the Dietary Service Supervisor (DSS) regarding residents' food preferences. The RD checked Resident 26's tray card; Resident 26's tray card did not indicate resident disliked green beans. During an interview on 11/16/22, at 03:03 PM, with [NAME] 1 (CK 1). There was a pink sticky note posted in front of CK 1 the pink note indicated, Resident 26 did not want green beans. CK 1 stated, she did not pay attention to the pink sticky note. CK 1 stated, normally DSS updated resident food preference in tray card, and she just followed the tray card. During a phone interview on 11/18/22, at 09:17 AM, with DSS. DSS stated, it is very important to honor resident food preference. DSS stated, the potential risk for not honoring resident food preference would cause the resident did not want to eat, then the resident would experience unplanned weight loss. During a review of the facility's policy and procedure (P&P) titled, Resident Food preference, revised 11/17/2022, the P&P indicated, POLICY: Protocol pertaining to Residents food preferences. PROCEDURE: .2. The resident food preferences should be identified on the tray card.3.Food preferences are recorded .tray card.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure complete and accurate documentation of medical records in accordance with acceptable professional standards and practices for two of four sampled residents (Resident 24 and Resident 13) when: 1. Resident 24's Physician Orders for Life Sustaining Treatment (POLST- a form that allows emergency medical services to provide treatment that the individual prefers before possibly transporting to an emergency facility) had orders for Do Not Attempt Resuscitation and Resident 24's Advance Health Care Directive (AHCD, a written instruction, such as living will or durable power of attorney for health care, recognized by state law, relating to the provisions of health care when the individual is incapacitate) was documented as Choice to Prolong Life. This failure had the potential to result in Resident 24 to not receive CPR (medical intervention used to restore circulatory and/or respiratory function that has ceased) which was her wish in case of a medical emergency. 2. Resident 13's POLST Section A had an order for Do Not Attempt Resuscitation (Allow Natural Death) and POLST Section B had an order for Full Treatment as Medical Interventions. This failure had the potential to result in Resident 13 receiving CPR which was against Resident 13's responsible party's (someone who makes decisions for another person) wishes for Resident 13 to not be resuscitated in case of a medical emergency. Findings: 1. During a review of Resident 24's admission Record (AR, a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated [DATE], the AR indicated, Resident 24 was admitted to from an acute care hospital on [DATE] to the facility, whose diagnoses included Right Femur (thigh bone) Fracture, Hypertension (high blood pressure), Anemia (lack of iron), Muscle Weakness, and Wound on Right Lower Leg. Resident 24's POLST, dated [DATE], indicated, . [X] Do Not Attempt Resuscitation/DNR (Allow Natural Death) . The POLST was signed by Resident 24's responsible party on [DATE]. Resident 24's physician signed the POLST on [DATE]. During a review of Resident 24's Minimum Data Set (MDS-comprehensive, standardized assessment of residents' functional capabilities and health needs), dated [DATE], the MDS indicated, . BIMS (Brief Interview for Mental Status) Summary Score . 15 [indicating cognitively intact] . During a review of Resident 24's Order Summary Report (OSR), dated [DATE], the OSR indicated, . DNR: Selective Treatment: Do Not Intubate. Trial Period of artificial nutrition . Order Date XXX[DATE] . During a review of Resident 24's AHCD, dated [DATE], the AHCD indicated, . Choice to Prolong Life . I want my life to be prolonged as long as possible within the limits of generally accepted health care standards . During a concurrent interview and record review, on [DATE], at 3:20 p.m., with Licensed Vocational Nurse (LVN) 2, Resident 24's EHR dated [DATE] was reviewed. LVN 2 stated, Resident 24's POLST was signed by the physician on [DATE], indicated Resident 24 was Do Not Attempt Resuscitation (DNR). LVN 2 stated, Resident 24's AHCD dated [DATE] specified that she wants to be full code or to prolong life. LVN 2 stated, having two conflicting information could cause a delay in Resident 24's care and her wish to be resuscitated not be followed. LVN 2 stated, the POLST should have been updated by a licensed nurse to full code status when Resident 24's AHCD was submitted to the facility on [DATE]. During an interview on [DATE], at 3:20 p.m., with Resident 24, in the activity room, Resident 24 stated, she wants the facility staff to perform CPR in case she suffers from cardiac arrest (sudden, unexpected loss of heart function, breathing, and consciousness). Resident 24 stated, she recently completed her AHCD and her wish was to be full code (perform CPR) at this time. During a concurrent interview and record review, on [DATE], at 11:55 a.m., with the Social Services Designee (SSD), Resident 24's EHR dated [DATE] was reviewed. The SSD stated she facilitates the care conference with the resident or responsible party within two to three days of admission to the facility. The SSD stated, during the case conference, she reviews the code status with the resident or responsible party. The SSD stated, she sometimes documents the conversation in the EHR but not all the time. The SSD stated, she doesn't recall reviewing Resident 24's AHCD and POLST. The SSD stated, Resident 24 could have a bad outcome. A full code resident was documented as DNR. We probably violated her rights. The SSD stated Resident 24's POLST and Physician Order should reflect the information stated in Resident 24's AHCD. During an interview on [DATE], at 12:02 p.m., with the Director of Nursing (DON), the DON stated the code status in POLST and AHCD should be the same. The DON validated, Resident 24's POLST was marked as DNR and Resident 24's wishes on her AHCD was to prolong life. The DON stated, if they [POLST and AHCD] were not the same, there was a potential for the resident's wishes to not be followed and the potential for delay in providing lifesaving CPR to Resident 24. The DON stated, the facility failed to follow their policy in completing Resident 24's advance directives and maintain an accurate records. During a review of facility's document titled, Physician Orders for Life-Sustaining Treatment (POLST), dated [DATE], the POLST indicated, . A copy of the signed POLST form is a legally valid physician order . POLST complements an Advance Directive and is not intended to replace that document . Directions to Health Care Provider . POLST does not replace the Advance Directive. When available, review the Advance Directive and POLST form to ensure consistency, and update forms appropriately to resolve any conflicts . During a review of the facility's policy and procedure (P&P) titled, Charting and Documentation, dated 01/2019 was reviewed. The P&P indicated, . All services provided to the resident, progress toward the care plan goals, or changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record . During a review of the facility's policy and procedure (P&P) titled, Advance Directive, dated 07/2016 was reviewed. The P&P indicated, . Advance directives will be respected in accordance with state law and facility policy . 6. Prior to or upon admission of a resident, the social services director or designee will inquire of the resident, his/her legal representative, about the existence of any written advance directive . 15. In accordance with current Omnibus Budget Reconciliation Act (OBRA, also known as the Nursing Home Reform Act of 1987, federal standards of how care should be provided to nursing home residents) definitions and guidelines governing advance directives, our facility has defined advance directives as preferences regarding treatment options . During a professional reference review retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5297955/, titled How to keep good clinical records, dated [DATE], indicated, .Clinical record keeping is an integral component in good professional practice and the delivery of quality healthcare. Regardless of the form of the records (i.e., electronic or paper), good clinical record keeping should enable continuity of care and should enhance communication between different healthcare professionals. Consequently, clinical records should be updated, where appropriate, by all members of the multidisciplinary team that are involved in a patient's care . Continuity in clinical notes is of vital importance to patient care as, in the current medical environment, many different healthcare professionals are involved in the treatment of a single patient. Making sure that clinical notes are up to date and completed accurately with sufficient information will ensure that the proper information is provided to all relevant healthcare workers and will aid them in potential future decisions . During a professional reference reviewed retrieved from https://journals.lww.com/cnsjournal/Fulltext/2014/11000/Quality_Nursing_Documentation_in_the_Medical.4.aspx titled Quality Nursing Documentation in the Medical Record dated [DATE], .The medical record must be maintained in a manner that follows applicable regulations, accreditation standards, professional practice standards, and legal standards. All providers of healthcare for the patient are responsible for knowing the required documentation and are held accountable for their entries and for missing information in the medical record . An accurate medical record improves the quality of care through enhancing effective communication across the continuum of care for the patient, thus protecting the patient from potential harm Nursing documentation must be time sensitive: To ensure that all nursing documentation is a true reflection of the patient's condition and care, the nurse must document at the time of the event or shortly afterward .A failure to maintain a reasonable standard of documentation of nursing interventions administered to a patient could be viewed as professional misconduct .the nurse has an obligation to accurately document. The Lippincott Manual of Nursing Practice 10th Edition, dated 2014, page 16-17 indicated, Standards of practice General Principles . 1 The practice of professional nursing has standards of practice setting minimum levels of acceptable performance for which its practitioners are accountable .b. These standards provide patients with a means of measuring the quality of care they receive .5. A deviation from the protocol should be documented in the patient's chart with clear, concise statements of the nurse's decisions, actions, and reasons for the care provided, including any apparent deviation . Legal claims most commonly made against professional nurses include the following departures from appropriate care: failure to assess the patient properly or in a timely fashion, follow physician orders, follow appropriate nursing measures, communicate information about the patient, adhere to facility policy or procedure, document appropriate information in the medical record . 2. During a review of Resident 13's AR, dated [DATE], the AR indicated, Resident 13 was admitted from an acute care hospital on [DATE] to the facility, whose diagnoses included Unspecified Dementia (a decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities), Anemia, Muscle Weakness, and Hypertension. Resident 13's POLST, dated [DATE], indicated, Section A . [X] Do Not Attempt Resuscitation/DNR (Allow Natural Death) . Section B . [X] Full Treatment - primary goal of prolonging life by all medically effective means . The POLST was signed by Resident 13's responsible party on [DATE]. Resident 13's physician signed the POLST on [DATE]. During a review of Resident 13's MDS, dated [DATE], the MDS indicated, . BIMS Summary Score . 8 [indicating cognitively moderately impaired] . During a review of Resident 13's OSR, dated [DATE], the OSR indicated, . DNR, Trial Period of Full Treatment, Trial Period of artificial nutrition . Order Date XXX[DATE] . During a review of Resident 13's AHCD, dated [DATE], the AHCD indicated, . 1. END-OF-LIFE DECISION . I do not desire that my life be prolonged to the greatest extent possible. I do not want to have life-prolonging care, treatment, services and/or procedures, including nutrition and hydration, provided or continued to me if the burdens of such treatment outweigh the expected benefits . During a concurrent interview and record review, on [DATE], at 9:38 a.m., with LVN 1, Resident 13's EHR dated [DATE] was reviewed. LVN 1 stated, Resident 13's POLST was signed by the physician on [DATE], indicated, POLST Section A was Do Not Attempt Resuscitation/DNR (Allow Natural Death) and Section B was Full Treatment with a primary goal of prolonging life by all medically effective means. LVN 1 stated, the form was incorrectly completed and the section for the preparer's name was blank. LVN 1 stated, we don't know who assisted the RP in completing the POLST form. LVN 1 stated, having two conflicting information [POLST Section A and Section B] could cause a delay in Resident 13's care and her wishes to be not resuscitated be followed. LVN 1 stated, the conflicting POLST information could result to confusion among facility staff and emergency responders. During a concurrent interview and record review, on [DATE], at 11:55 a.m., with the SSD, Resident 13's EHR dated [DATE] was reviewed. The SSD stated, she facilitates the care conference with the resident or responsible party within two to three days of admission to the facility. The SSD stated, during the case conference, she reviews the code status with the resident or responsible party. SSD stated, she sometimes documents the conversation in the EHR but not all the time. The SSD stated, she doesn't recall reviewing Resident 13's AHCD and POLST. The SSD stated Resident 13's POLST and Physician Order should reflect the information stated in Resident 13's AHCD. During an interview on [DATE], at 12:02 p.m., with the DON, the DON stated, the code status in POLST and AHCD should be the same. The DON validated, Resident 13's POLST was marked as DNR [Section A] and Full Treatment [Section B] and Resident 13's wishes on her AHCD was Do Not Attempt Resuscitation. The DON stated, if they [POLST and AHCD] were not the same, there was a potential for Resident 13's wishes to not be followed and potentially receiving unwanted CPR. The DON stated, the facility failed to follow their policy in completing Resident 13's advance directives and maintain an accurate records. During a review of facility's document titled, Physician Orders for Life-Sustaining Treatment (POLST), dated [DATE], the POLST indicated, . A copy of the signed POLST form is a legally valid physician order . POLST complements an Advance Directive and is not intended to replace that document . During a review of the facility's policy and procedure (P&P) titled, Charting and Documentation, dated 01/2019 was reviewed. The P&P indicated, . All services provided to the resident, progress toward the care plan goals, or changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record . During a review of the facility's policy and procedure (P&P) titled, Advance Directive, dated 07/2016 was reviewed. The P&P indicated, . Advance directives will be respected in accordance with state law and facility policy . 6. Prior to or upon admission of a resident, the social services director or designee will inquire of the resident, his/er legal representative, about the existence of any written advance directive . 15. In accordance with current Omnibus Budget Reconciliation Act (OBRA, also known as the Nursing Home Reform Act of 1987, federal standards of how care should be provided to nursing home residents) definitions and guidelines governing advance directives, our facility has defined advance directives as preferences regarding treatment options . During a professional reference review retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5297955/, titled How to keep good clinical records, dated [DATE], indicated, .Clinical record keeping is an integral component in good professional practice and the delivery of quality healthcare. Regardless of the form of the records (i.e., electronic or paper), good clinical record keeping should enable continuity of care and should enhance communication between different healthcare professionals. Consequently, clinical records should be updated, where appropriate, by all members of the multidisciplinary team that are involved in a patient's care . Continuity in clinical notes is of vital importance to patient care as, in the current medical environment, many different healthcare professionals are involved in the treatment of a single patient. Making sure that clinical notes are up to date and completed accurately with sufficient information will ensure that the proper information is provided to all relevant healthcare workers and will aid them in potential future decisions . During a professional reference reviewed retrieved from https://journals.lww.com/cnsjournal/Fulltext/2014/11000/Quality_Nursing_Documentation_in_the_Medical.4.aspx titled Quality Nursing Documentation in the Medical Record dated [DATE], .The medical record must be maintained in a manner that follows applicable regulations, accreditation standards, professional practice standards, and legal standards. All providers of healthcare for the patient are responsible for knowing the required documentation and are held accountable for their entries and for missing information in the medical record . An accurate medical record improves the quality of care through enhancing effective communication across the continuum of care for the patient, thus protecting the patient from potential harm Nursing documentation must be time sensitive: To ensure that all nursing documentation is a true reflection of the patient's condition and care, the nurse must document at the time of the event or shortly afterward .A failure to maintain a reasonable standard of documentation of nursing interventions administered to a patient could be viewed as professional misconduct .the nurse has an obligation to accurately document. The Lippincott Manual of Nursing Practice 10th Edition, dated 2014, page 16-17 indicated, Standards of practice General Principles . 1 The practice of professional nursing has standards of practice setting minimum levels of acceptable performance for which its practitioners are accountable .b. These standards provide patients with a means of measuring the quality of care they receive .5. A deviation from the protocol should be documented in the patient's chart with clear, concise statements of the nurse's decisions, actions, and reasons for the care provided, including any apparent deviation . Legal claims most commonly made against professional nurses include the following departures from appropriate care: failure to assess the patient properly or in a timely fashion, follow physician orders, follow appropriate nursing measures, communicate information about the patient, adhere to facility policy or procedure, document appropriate information in the medical record .

Based on interview and record review, the facility failed to ensure a Registered Nurse (RN) was scheduled and in the facility for at least eight consecutive hours a day seven days per week, when the facility did not have an RN for 21 of 72 days from April 2022 through June 2022. This failure resulted in an inadequate RN facility staffing and the failure to have direct RN clinical oversight for a minimum of eight hours, seven days per week. Findings: During a concurrent interview and record review on 11/18/22, at 9:42 a.m., with the Director of Nursing (DON), the DON stated, she assumed the position of DON after she passed her board on October 17, 2022. She stated the DON at the time was the Minimum Data Set Nurse (MDSN) and there were on-call RN's covering the weekends. The DON reviewed the Licensed Nursing schedules for the month of April 2022, May 2022 and June 2022. DON stated she was still the Director of Staff Development (DSD) during those times. The DON stated, she had been rotating with the MDSN to cover the weekend RN eight hours coverage. During a concurrent interview and record review with the Administrator in Training (AIT) on 11/18/22, at 10:16 a.m., the AIT reviewed the facility Licensed Nursing (LN) staffing schedule dated 4/2022, 5/2022 and 6/2022 and indicated there was no RN working at the facility on 4/16, 4/17, 4/23, 4/24, 5/7, 5/8, 5/14, 5/15, 5/21, 5/22, 5/24, 5/28, 5/29, 6/4, 6/5, 6/11, 6/12, 6/18, 6/19, 6/25, and 6/26. The AIT stated there were weekends where the facility did not have an RN coverage. The AIT stated the facility was actively looking for RN and the corporate put ads on job website. The AIT stated the facility applied for RN waiver back in May 2022 but have not heard anything back if it was denied. The AIT stated for now the facility only had two RN's, the DON and the MDSN and have revised the schedules of the DON and the MDSN in order to have eight hour consecutive RN coverage daily and on weekends. The AIT stated he did not have a policy to ensure the facility followed the regulation for RN coverage for eight hours daily, seven days a week. No additional information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on dietary observations, interviews, and record reviews, the facility failed to ensure safe and sanitary food preparation and storage practices in the kitchen when: 1. The two compartment sink used for food preparation did not have an air gap (an air gap refers to a fixture that provides back-flow prevention). This failure had the potential for back flow from the drain to contaminate the sink and the potential to cause foodborne illness for 28 of 28 sampled residents who received food from the kitchen. 2. The hand washing sink did not provide enough hot water to wash hands effectively. This failure had the potential risk to cause foodborne illness for 28 of 28 sampled residents who received food from the kitchen. 3. There was calcium build up on the curtain of ice machine where ice touched before traveling to the ice storage bin. This failure had the potential risk to cause foodborne illness for 28 of 28 sampled residents who received ice from the kitchen. 4. There was food residual and calcium build up on the top of the dish machine and calcium build up on the door of dish machine .This failure had the potential risk to cross contamination for 28 of 28 sampled residents who received food from the kitchen. 5. The can opener based in the kitchen was not kept in sanitary condition. This failure had the potential risk to cause foodborne illness for 28 of 28 sampled residents who received food from the kitchen. 6. The floor under the stainless-steel counters, behind reach in refrigerators and behind the reach in freezers had food crumbs, trash, black grime, dust, black/brown debris. This failure had the potential risk to promote bacteria and virus grow and attract pests which could cause cross contamination for 28 of 28 sampled residents who received food from the kitchen. 7. The stainless shelves used to store clean kitchenware were covered with dust, food residual, and black/brown debris. This failure had the potential risk to attract pests and promote bacteria and virus grow which could cause cross contamination for 28 of 28 sampled residents who received food from the kitchen. 8. The wooden shelves in dry storage room were peeling and had chipped paint. This failure had the potential risk to cause foodborne illness for 28 of 28 sampled residents who received food from the kitchen. 9. There were 22 plastic container covers in dry storage used to store food items that were covered with dust and brown debris. This failure had the potential risk to cause foodborne illness for 28 of 28 sampled residents who received food from the kitchen. 10. There was a package of expired mini corn tortilla found in the number two reach in refrigerator. This failure had the potential risk for 28 of 28 sampled residents who received food from the kitchen consumed expired foods. 11. One dietary staff with a beard did not wear a beard restraint while preparing foods. This failure had the potential risk to cause foodborne illness for 28 of 28 sampled residents who received food from the kitchen. 12. There were several opened food items not sealed correctly in the reach in freezer number one and number two. This failure result in unseal food items were exposing to air in the freezers which potentially causing freezer burn and affecting the quality of the food for 28 of 28 sampled residents who received food from the kitchen. The facility's failures to ensure a safe and sanitary condition resulted in the likelihood of microorganisms that harbor foodborne pathogens to come in contact with residents' food which would cause food-borne illness to a population of 28 of 28 residents who received food from the kitchen and are medically compromised. (Cross refereed 801) 1. During a concurrent observation and interview on 11/16/22, at 09:37 AM with the Registered Dietitian (RD) and [NAME] 1 (CK 1). CK 1 stated, she used the two compartment sinks for food preparation (prep). The RD stated, No air gap for the 2-compartment prep sinks. During an interview on 11/16/22, at 11:02 AM, with Administrator in Training (AIT). AIT could not find an air gap for the two compartment prep sinks. AIT stated, I am not familiar what an air gap for the -two compartment prep sinks. During a review of the Federal Food and Drug Administration (FDA) 2017 Food Code, indicated A plumbing system shall be installed to preclude back flow of a solid, liquid, or gas contaminant into the water supply system at each point of use at the food establishment, including on a hose [NAME] if a hose is attached or on a hose [NAME] if a hose is not attached and back flow prevention is required by LAW, by: (A) Providing an air gap as specified under 5-202.12. 5-202.13 indicated 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 one inch. In addition, During periods of extraordinary demand, drinking water systems may develop negative pressure in portions of the system. If a connection exists between the system and a source of contaminated water during times of negative pressure, contaminated water may be drawn into and foul the entire system. Providing an air gap between the water supply outlet and the flood level rim of the plumbing fixture or equipment prevents contamination that may be caused by back flow. 2. During a concurrent observation and interview on 11/15/22, at 9:44 AM, with [NAME] 1(CK 1). The hand washing sink water temperature was warm. CK 1 checked the hand washing sink water temperature was 91 Degrees Fahrenheit. CK 1 stated, the hand washing sink water temperature was warm. During a concurrent observation and interview on 11/15/22, at 10:50 AM, with Administrator in Training (AIT). AIT checked the hand washing sink water temperature and the temperature was 99.7 Degrees Fahrenheit. AIT stated the hand washing temperature supposed to be 105 -120 Degrees Fahrenheit. Nobody in the dietary reported to me the water is warm. During an interview on 11/16/22, at 09:37 AM, with the Registered Dietitian (RD), the RD stated the hand washing sink water temperature needed to be as hot as tolerated. RD could not verbalize what the hand washing sink water temperature need to be. During a review of the facility's policy and procedure (P&P) titled, Hand Washing, revised 11/2020, the P&P indicated, POLICY: Hand washing is essential in order to break the chain infection transmission. Hand washing is the single most important procedure for preventing nosocomial infections. PROCEDURE: .2. Use hot water, rinse hands well. During a review of the Federal Food and Drug Administration (FDA) 2017 Food Code, the FDA food code indicated, A handwashing sink shall be equipped to provide water at a temperature of at least 38° C (100°F) through a mixing valve or combination faucet, and Warm water is more effective than cold water in removing the fatty soils encountered in kitchens. An adequate flow of warm water will cause soap to lather and aid in flushing soil quickly from the hands. ASTM Standards for testing the efficacy of handwashing formulations specify a water temperature of 40°C ± 2°C (100 to 108°F). 3. During a concurrent observation and interview on 11/15/22, at 10:37 AM, with Administrator in Training (AIT) in front of ice machine. There was calcium build up on the curtain of ice machine where ice touched before traveling to the ice storage bin. AIT stated, the calcium build up not supposed to be there. During a review of the Federal Food and Drug Administration (FDA) 2017 Food Code, indicated, food-contact surfaces and utensils are to be clean to sight and touch. 4. During a concurrent observation and interview on 11/16/22, at 10:26 AM, with the Registered Dietitian (RD). The top of dish machine was covered with food residual and calcium build up. The door of the dish machine was also covered with calcium build up. The RD stated, the dish machine looks like had lime build up. The RD validated the top of dish machine was covered with food residual. During a review of the facility's policy and procedure (P&P) titled, Cleaning of Food preparation Areas, revised 11/2020, the P&P indicated .Nonfood contact surface of equipment shall be cleaned at such intervals as to keep them in a clean and sanitary condition. 5. During a concurrent observation and interview on 11/16/22, at 10:26 AM, with the Registered Dietitian (RD). The base of the can opener was observed to be covered with black/brown grime. The RD stated, there was build up on the sides of the base of the can opener. The RD stated, the potential risk for the buildup on the base of can opener was the growth of mold. The RD stated, we do not want the buildup or mold to get into the food when used can opener. During a review of the facility's policy and procedure (P&P) titled, Cleaning of Food preparation Areas, revised 11/2020, the P&P indicated .1. All kitchenware and food contact surface used in the preparation .food shall be cleaned after each use and thoroughly cleaned after each meal preparation.3.all food contact surface of equipment shall be handled . to protect from contamination 6. During a concurrent observation and interview on 11/16/22, at 10:26 AM, with the Registered Dietitian (RD). The floor under the stainless shelves, behind reach in refrigerators and behind reach in freezers were food crumbs, trash, black grime, dust and black/brown debris. The RD validated the floor under the stainless shelves, behind reach in refrigerators and behind the reach in freezers were food crumbs, trash, black grime, dust and black/brown debris. The RD stated, the potential risk for not keeping the floor clean was the growth of mold. According to the Federal Food and Drug Administration (FDA) 2017 Food Code, indicated, The objective of cleaning focuses on the need to remove . soil from non-food contact surfaces so that pathogenic microorganisms will not be allowed to accumulate, and insects and rodents will not be attracted. 7. During an observation on 11/15/22, at 09:54 AM, in the kitchen. The stainless shelves in front of the stove used to stored clean kitchenware were covered with dust, food residual, and black/brown debris. During a concurrent observation and interview on 11/16/22, at 09:37 AM, with the Registered Dietitian (RD) in front of stainless shelves. The RD acknowledged the stainless shelves in front of the stove used to stored clean kitchenware were covered with food residual, black/brown debris, and dust. According to the Federal Food and Drug Administration (FDA) 2017 Food Code, indicated, Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. Also, The objective of cleaning focuses on the need to remove . soil from non-food contact surfaces so that pathogenic microorganisms will not be allowed to accumulate, and insects and rodents will not be attracted. 8. During a concurrent observation and interview on 11/16/22, at 09:37 AM, with the Registered Dietitian (RD), in the dry storage room. The wooden shelves of the dry storage room were peeling and chipping. The RD acknowledged the wooden shelves of the dry storage room were peeling and chipping. The RD stated, We do not want the peeling and chipping paint get into the cans stored in the wooden shelves. During a review of the facility's policy and procedure (P&P) titled, SANITATION AND INFECTION CONTROL. SUBJECT: CANNED AND DRY GOODS STORAGE, dated 2018, the P&P indicated, . PROCEDURES: . 3. The storage area ( .shelves, .) will be clean .4. All food items will be stored .on .shelves or other surfaces that can be cleaned thoroughly. 9. During a concurrent observation and interview on 11/16/22, at 09:37 AM, with the Registered Dietitian (RD), in the dry storage room. There were 22 plastic container covers in dry storage used to store food items covered with dust and brown debris. The RD used her hand and touched the covers of the plastic containers and stated, dusty. The RD stated the covers need to be clean. We do not want the dust to contaminate the foods store in the plastic containers. During a review of the facility's policy and procedure (P&P) titled, SANITATION AND INFECTION CONTROL. SUBJECT: CANNED AND DRY GOODS STORAGE, dated 2018, the P&P indicated, . PROCEDURES:1. Food storage areas will be clean, . According to the FDA Federal Food Code 2017, .Non-food contact surfaces . shall be kept free of accumulation of dust, dirt, food residue, and other debris. 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. 10. During a concurrent observation and interview on 11/15/22, at 10:35 AM, with Dietary Aide (DA ) 1. There was one opened package with approximately 30 pieces of mini corn tortilla in the reach in refrigerator number two. The manufacturer best buy date for the opened mini corn tortilla was October 24, 2022. DA 1 stated, this is out of date. It is not supposed in the refrigerator. DA 1 threw away the expired mini corn tortillas. During an interview on 11/16/22, at 09:37 AM, with the Registered Dietitian (RD), the RD stated, expired foods are not supposed to be kept in the kitchen because she did not want residents to get sick when consuming expired foods. During a review of the facility's policy and procedure (P&P) titled, EXPIRATION DATES, revised 11/2020, the P&P indicated, POLICY: To be sure all food is checked for a manufacture expiration date. 11. During an observation on 11/15/22, at 09:54 AM, with Dietary Aide (DA) 1, DA 1 was observed with facial hair (beard). DA 1's beard was not covered. During an interview on 11/16/22, at 09:37 AM, with the Registered Dietitian (RD), the RD stated DA 1 required to wear a beard restraint while working in kitchen. During a review of the facility's policy and procedure (P&P) titled, SANITATION AND INFECTION CONTROL. SUBJECT: PERSONAL HYGIENE, dated 2018, the P&P indicated, PROCEDURES: .6. Breads .should be covered during meal preparation and service. 12. During a concurrent observation and interview on 11/15/22, at 11:12 AM, with [NAME] (CK) 1. There was a box of opened corn kernel exposed to the air in reach in freeze number one. There was a box of opened pork sausage exposed to air in reach in freezer number two. CK 1 stated, we supposed to seal the opened food items, so they did not get freezer burn. During an interview on 11/16/22, at 09:37 AM, with the Registered Dietitian (RD), the RD stated opened food items in the freezers needed to be sealed to prevent freezer burn. During a review of the facility's policy and procedure (P&P) titled, SANITATION AND INFECTION CONTROL. SUBJECT: FREEZER STORAGE, dated 2018, the P&P indicated, PROCEDURES: .5. All foods should be stored in an airtight .to prevent freezer burn.