**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure care that promoted rights of the resident and enhancement of quality of life for one of six sampled residents (Resident 147) when resident 147 was not allowed to smoke. This failure resulted in Resident 147 not being able to smoke since admission which led to decreased sense of pleasure and increased anxiety. Findings: During a review of Resident 147's admission Record (AR- document containing resident personal information), dated 3/6/25, the AR indicated, Resident 147 was admitted to the facility on [DATE], with diagnoses which included psychosis not due to a substance or known physiological condition (a mental health condition characterized by a loss of contact with reality. It is a state of altered perception, cognition, and behavior), major depressive disorder (a common and serious mental health condition characterized by persistent feelings of sadness, loss of interest, and other symptoms that significantly interfere with daily life), schizoaffective disorder (a chronic mental health condition that combines symptoms of schizophrenia and a mood disorder, such as depression or bipolar disorder), opioid dependence (physical and psychological reliance on opioids, a substance found in certain prescription pain medications and illegal drugs) and insomnia (a common sleep disorder characterized by difficulty falling asleep, staying asleep, or waking up too early and feeling unrested. It can significantly impact daily life, leading to fatigue, irritability, difficulty concentrating, and reduced productivity). During a review of Resident 147's Minimum Data Set (MDS- a resident assessment tool) assessment, dated 3/5/25, the MDS assessment indicated Resident 147's Brief Interview for Mental Status (BIMS- an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) assessment score was 14 out of 15 which indicated Resident 147 had no cognitive deficit (a decline in thinking abilities, like memory, reasoning, and problem-solving). During a review of Resident 147's Progress Note, dated 3/4/25, the Progress Note indicated, .MD [medical doctor] .was in house and spoke to resident and offered her a nicotine patch, but she declined it .MD . recommended for her to not smoke until she recovers from being intubated (a procedure that involves inserting a tube into a patient's airway to help them breathe) at acute [hospital] . During a concurrent observation and interview on 3/4/25 at 2:14 p.m. with Resident 147 in Resident 147's room, Resident 147 was seen sitting in bed rubbing her hands together and frequently repositioning. Resident 147 stated she had not been allowed to smoke since admitted to the facility. Resident 147 stated, I want to be able to smoke it is the only pleasure I have. Resident 147 stated not being allowed to smoke made her feel anxious. Resident 147 stated she was aware of the MD's recommendation to not smoke. Resident 147 stated the Director of Nursing (DON) provided education to her and her mother on the risks of smoking before her throat was healed. Resident 147 stated she had expressed, since admission, to the DON and facility staff she wanted to smoke despite the recommendation not smoke. During an interview on 3/5/25 at 4:50 p.m. with Certified Nursing Assistant (CNA) 4, CNA 4 stated Resident 147 was alert and able to make her needs known. CNA 4 stated she was informed by the licensed nurse; Resident 147 could not smoke until her throat was healed. CNA 4 stated Resident 147 had expressed, despite ongoing education, she wanted to smoke. CNA 4 stated she expected all resident rights and preferences to be upheld. CNA 4 stated it was Resident 147's right to smoke against medical advice. During an interview on 3/6/25 at 8:15 a.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated smoking was a resident right, and all residents should be allowed to smoke if they wanted. LVN 2 stated the role of the nurse was to educate Resident 147 on the risks and benefits of smoking, potential risks to smoking against medical advice and then uphold Resident 147's choice. During an interview on 3/6/25 at 8:21 a.m. with LVN 1, LVN 1 stated she was aware Resident 147 wanted to smoke, since admission, despite medical recommendation not to. LVN 1 stated it was expected all residents received an admission smoking screen by the Social Services Supervisor (SSS) to determine if each resident was a smoker. LVN 1 stated she did not know if Resident 147 had an admission smoking screen completed. During an interview on 3/6/25 at 8:26 a.m. with the SSS, The SSS stated she was responsible to complete an admission smoking screen on all residents. The SSS stated Resident 147 was not identified as a smoker during the admission smoking screen. The SSS stated after completion of Residents 147's admission smoking screen she was made aware Resident 147 was a smoker and wanted to smoke. The SSS stated Resident 147 was advised not to smoke until her throat was healed. The SSS stated Resident 147 had the right to smoke against medical advice if she wanted. During a concurrent interview and record review on 3/6/25 at 8:30 a.m. with the Activities Director (AD), the facility's Resident Smoking Binder, undated, was reviewed. The AD stated the Resident Smoking Binder was up to date and included all residents within the facility who smoked. The AD stated Resident 147's name was not listed in the Resident Smoking Binder. The AD stated it was her responsibility to complete a Resident Safe Smoking Assessment (an assessment to determine if supervision is required for smoking, or if a resident is safe to smoke at all) on every resident who smoked. The AD stated no Resident Safe Smoking Assessment was completed for Resident 147. The AD stated Resident 147 had expressed to her she wanted to smoke. The AD stated Resident 147 was able to make her needs known and had the right to smoke against medical advice. During an interview on 3/6/25 at 8:36 a.m. with the DON, the DON stated Resident 147 was able to make her needs known and was her own responsible party. The DON stated Resident 147 had the right to make her own healthcare choices. The DON stated he expected all resident healthcare choices and requests to be respected and implemented, per facility policy. The DON stated it was Resident 147's right to smoke. The DON stated Resident 147 was not identified as a smoker on her admission smoking screen. The DON stated he expected all resident admission smoking screens to be completed accurately. The DON stated Resident 147's Resident Safe Smoking Assessment had not been completed. The DON stated he expected the Resident Safe Smoking Assessment to be completed once a resident was identified as a smoker, per facility policy. The DON stated Resident 147's medical team recommended Resident 147 not to smoke until her throat was healed. The DON stated Resident 147 received education from the provider, licensed nurses and himself on the risks and benefits of smoking before her throat was healed. The DON stated he was aware Resident 147 wanted to smoke despite the education. The DON stated Resident 147 had the right to smoke against medical advice. The DON stated Resident 147's rights were violated when she was not allowed to smoke for eight days, since admitted . During a review of the facility's job description document titled, Certified Nursing Assistant, dated 2023, the document indicated, .Promotes and protects all residents' rights . During a review of the facility's job description document titled, Charge Nurse, dated 2023, the document indicated, .Performs rounds to ensure resident needs are being met .collaborates with other members of the interdisciplinary team as needed to ensure residents' needs are holistically met .Promotes and protects all resident's rights . During a review of the facility's job description document titled, Social Services Director, dated 2023, the document indicated, .The Social Services Director ensures that staff members are knowledgeable about Resident's Rights and encourages staff to maintain and enhance each resident's dignity in recognition of each resident's individuality. The Director will also advocate for residents and assist them in assertion of their rights within the facility . Promotes and protects all residents' rights . During a review of the facility's job description document titled, Activities Director, dated 2023, the document indicated, .The Activities Director is responsible for directing the development, implementation, supervision and ongoing evaluation of the activities program designed to meet the social, psychosocial and therapeutic needs of the resident . this includes .approaches that are individualized to match the skills, abilities, and interest/preferences of each resident .directing the activity program includes scheduling of activities .monitoring the response, reviewing and evaluating the response to the programs to determine is the activities meet the assessed needs of the resident, and making revisions as necessary . During a review of the facility's policy and procedure (P&P) titled, Activities, dated 11/2024, the P&P indicated, .It is the policy of this facility to provide an ongoing program to support residents in their choices of activities based don their comprehensive assessment, care plan, and preferences .to meet the interests of each resident, as well as support their physical, mental, and psychosocial well-being .intended to enhance her/his sense of well-being and to promote or enhance physical cognitive, and emotional health .that promote self-esteem, pleasure, comfort .activities will be designed with the intent to .enhance the resident's sense of well-being .reflect resident's interests .reflect choices of the residents . During a review of the facility's P&P titled, Resident Smoking, dated 11/2024, the P&P indicated, .Resident's who smoke will be further assessed, using the Resident Safe Smoking Assessment, to determine whether or not supervision is required for smoking, or if the resident is safe to smoke at all .The interdisciplinary team, with guidance from the physician, will help to support the resident's right to make an informed decision regarding smoking .Documentation to support decision making will be included in the medical record, including but not limited to: Resident's wishes .Assessment of relevant functional and cognitive factors affecting ability to smoke safely . During a review of the facility's P&P titled, Resident Right's, dated 11/2024, the P&P indicated, .The resident has the right to a dignified existence .and access to .services inside and outside the facility .The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States .The resident has the right to .request, refuse, and/or discontinue treatment .The resident has a right to choose activities .The resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe and homelike environment for one of two sampled residents when Resident 12's low air loss machine (designed to distribute patient's body weight over a broad surface area and help skin breakdown) was turned off. This failure had the potential for Resident 12 to develop skin breakdown which could result in pressure ulcer development. Findings: During a concurrent observation and interview on 3/5/25 at 9:40 a.m. in Resident 12's room, Resident 12 was seen lying in bed, covered with blanket and yelling out. Resident 12 did not answer questions asked. Resident 12's bed was positioned in lowest position and had a low air loss mattress. Resident 12's low air loss mattress was turned off and was unplugged from the wall. During a review of Resident 12's admission Record, (AR) dated 3/6/25, the AR indicated Resident 12 was re-admitted to the facility on [DATE] with diagnoses which included hemiplegia (total paralysis of the arm, leg, and trunk of the same side of the body) and hemiparesis (is a condition characterized by weakness or paralysis) dementia (the loss of thinking, remembering, and reasoning) and muscle weakness. During a review of Resident 12's Minimum Data Set (MDS- an assessment tool used to identify resident cognitive[pertaining to reasoning, memory and judgement] and physical functional level), assessment dated [DATE], indicated Resident 12's Brief Interview for Mental Status (BIMS-screening tool used in nursing home to assess cognition) assessment score was 10 out of 15 (0-15 scale [0-6 severe cognitive deficit, 7-12 moderate cognitive deficit, 13-15 no cognitive deficit]) indicating Resident 12 had moderate cognitive deficit. During a review of Resident 12's Order Summary Report, dated 3/6/25 indicated, . low air loss mattress r/t [related to] limited mobility . During an concurrent observation and interview on 3/5/25 at 9:42 a.m. with Certified Nurse Assistant (CNA) 1, CNA 1 stated she was familiar with Resident 12's care. CNA 1 checked the low air loss machine of Resident 12 and stated the low air loss machine was off and it was unplugged. CNA 1 stated, The machine was supposed to be on at all times when a resident has an order to prevent skin breakdown. CNA 1 plugged the machine and turned the machine on. During an interview on 3/5/25 at 9:50 a.m. with Licensed Vocational Nurse (LVN)1, LVN 1 stated she was Resident 12's nurse. LVN 1 stated Resident 12's has an order for low air loss mattress and should have been on at all times to prevent Resident 12 from developing pressure ulcer (localized skin damage that developed as a result of prolonged pressure). LVN 1 stated it was the responsibility of the nursing staff to ensure the low air loss mattress machine was on at all times. During an interview on 3/5/25 at 10:55 a.m. with CNA 2, she stated she was the CNA assigned to Resident 12 and was familiar with his care. CNA 2 stated the low air loss mattress was off in the morning but did not recall if it was unplugged. CNA 2 stated the machine should have been on at all times. During an interview on 3/7/25 at 5:55 p.m. with the Director of Nursing (DON), the DON stated his expectation was for the low air loss machine to be on at all times when resident was in bed to prevent skin breakdown. The DON stated it was the responsibility of the nursing staff to ensure the low air loss machine was on and functioning properly. The DON stated not having the low air machine on put Resident at risk of developing skin ulcer. During a review of the facility's policy and procedure (P&P) titled, Safe and Homelike Environment, dated 2024, the P&P indicated, . In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment . receive care and services safely . and does not pose a safety risk .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Infection Preventionist (IP) have the specific competencies, and skill sets necessary to ensure residents who required Enhanced Barrier Precaution (EBP) were properly managed to prevent the risk for infections for seven of seven sampled residents (Residents' 10, 30, 39, 40, 29, 37 and 28) when the IP demonstrated a breakdown in following critical infection control policies and procedures. These failures placed Residents' 10, 30, 39, 40, 29, 37 and 28 at increased risk for infection. Findings: During a review of Resident 10's admission Record, (AR) dated 3/6/25, the AR indicated Resident 10 was admitted to the facility on [DATE] with diagnoses which included diabetes (high sugar level in the blood), open wound to right knee, open wound to left knee and muscle weakness. During a review of Resident 10's Minimum Data Set (MDS- an assessment tool used to identify resident cognitive[pertaining to reasoning, memory and judgement] and physical functional level), assessment dated [DATE], indicated Resident 10's Brief Interview for Mental Status (BIMS-screening tool used in nursing home to assess cognition) assessment score was 14 out of 15 (0-15 scale [0-6 severe cognitive deficit, 7-12 moderate cognitive deficit, 13-15 no cognitive deficit]) indicating Resident 10 had no cognitive deficit. During a review of Resident 28's admission Record, (AR) dated 3/6/25, the AR indicated Resident 28 was re-admitted to the facility on [DATE] with diagnoses which included retention of urine, hemiplegia and hemiparesis and muscle weakness. During a review of Resident 28's MDS assessment dated [DATE], indicated Resident 28's BIMS assessment score was 15 out of 15 indicating Resident 28 had no cognitive deficit. During a review of Resident 29's admission Record, (AR) dated 3/6/25, the AR indicated Resident 29 was admitted to the facility on [DATE] with diagnoses which included dementia () and diabetes During a review of Resident 29's MDS assessment dated [DATE], indicated Resident 29's BIMS assessment was not able to complete and staff assessment was conducted which indicated Resident 29 had a score of 2 indicating Resident 29 was moderately impaired, decisions poor and required cues and supervision. During a review of Resident 30's admission Record, (AR) dated 3/6/25, the AR indicated Resident 30 was admitted to the facility on [DATE] with diagnoses which included diabetes, surgical aftercare, and chronic ulcer of left foot. During a review of Resident 30's MDS assessment dated [DATE], indicated Resident 30's BIMS assessment score was 13 out of 15 indicating Resident 30 had no cognitive deficit. During a review of Resident 37's admission Record, (AR) dated 3/6/25, the AR indicated Resident 30 was admitted to the facility on [DATE] with diagnoses which included open wound, non-pressure chronic ulcer of right heel and muscle weakness. During a review of Resident 37's MDS assessment dated [DATE], indicated Resident 37's BIMS assessment score was 15 out of 15 indicating Resident 37 had no cognitive deficit. During a review of Resident 39's admission Record, (AR) dated 3/6/25, the AR indicated Resident 39 was admitted to the facility on [DATE] with diagnoses which included cellulitis of left lower limb, diabetes and muscle weakness. During a review of Resident 39's MDS assessment dated [DATE], indicated Resident 39's BIMS assessment score was 15 out of 15 indicating Resident 39 had no cognitive deficit. During a review of Resident 40's admission Record, (AR) dated 3/6/25, the AR indicated Resident 28 was admitted to the facility on [DATE] with diagnoses which included cellulitis of unspecified part of limb and pressure ulcer of sacral region. During a review of Resident 40's MDS assessment dated [DATE], indicated Resident 40's BIMS assessment score was 15 out of 15 indicating Resident 40 had no cognitive deficit. During a concurrent interview and record review on 3/5/25 at 3:23 p.m. with IP, IP stated she had been the IP in the facility for over a year. The IP stated her role includes monitoring infection control and antibiotic use. The IP stated there are seven residents on EBP. The IP stated all seven residents on EBP did not have physician's orders. The IP stated according to facility policy and procedure, she should have placed the order on the day Residents' 10, 30, 39, 40, 29, 37 and 28 were placed on EBP. The IP stated Residents' 10, 30, 39, 40, 29, 37 and 28 did not have EBP care plans and should have. The IP stated care plans should be started within 24 hours. The IP stated she did not complete assessment or documentation for the residents' wounds. The IP stated as a result she did not know whether resident wounds were improving or getting worse because there was no documentation. During an interview on 3/7/25 at 6:05 p.m. with the Director of Nursing (DON), the DON stated the IP was responsible in identifying residents belonging in the EBP and notifying staff of the precautions needed to care for residents. The DON stated physician order was needed as soon as a resident was placed on EBP. The DON stated the IP should have called Medical Doctor (MD) and get the order. The DON stated his expectation was for the IP to do her job. During a review of facility document titled, Infection Preventionist, Job Description dated 2023, the document indicated, . Establishes facility-wide systems for the prevention, identification, reporting, investigation, and control of infections and communicable diseases . Maintains documentation of infection prevention and control program activities .

**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 27) were provided special eating equipment when Resident 27's lunch was not served on an adaptive equipment scoop plate per her meal ticket. This failure resulted in Resident 27's individualized care needs not met which led to difficulty eating, delayed in finishing her meals and the potential risk for decreased oral intake. Findings: During a review of Resident 27's admission Record (AR- document containing resident personal information), dated 3/6/25, the AR indicated, Resident 27 was admitted to the facility on [DATE], with diagnoses which included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (complete and partial weakness on the left side of the body following a stroke [blood flow to the brain is decreased, causing brain cells to die]) , chronic obstructive pulmonary disease (COPD-air flow obstruction and inflammation of the airways, leading to difficulty breathing) with acute exacerbation (sudden worsening of COPD symptoms, such as increased breathlessness, cough, and/or sputum production, that requires additional treatment and can worsen health status), type 2 diabetes mellitus with other diabetic ophthalmic complication (high levels of sugar in the blood that have caused vision problems) , muscle weakness and chronic kidney disease (a long-term condition where the kidneys gradually lose their ability to filter waste products and excess fluid from the blood). During a review of Resident 27's Minimum Data Set (MDS- a resident assessment tool) assessment, dated 1/18/25, the MDS assessment indicated Resident 27's Brief Interview for Mental Status (BIMS- an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) assessment score was 15 out of 15 which indicated Resident 27 had no cognitive deficit (a decline in thinking abilities, like memory, reasoning, and problem-solving). The MDS assessment indicated Resident 27's functional abilities (the capacity to perform daily tasks and activities) had impairments on both sides of her upper extremities. During a concurrent observation and interview on 3/4/25 at 11:55 a.m. with the Certified Dietary Manager (CDM) in the kitchen during tray line (where meals are prepared, organized, and distributed o patients), Resident 27's lunch was seen on a regular plate. Resident 27's meal ticket stated, Adaptive Equipment: Scoop Plate. The CDM stated Resident 27's lunch was on a regular plate. The CDM stated per Resident 27's meal ticket she required a scoop plate. The CDM stated the cook and dietary aide were responsible to plate meals per the meal ticket. The CDM stated occupational therapy (OT) determined Resident 27's need for an adaptive scoop plate and she placed the order on the meal ticket. The CDM stated all adaptive eating equipment devices were listed on the meal ticket. The CDM stated a scoop plate had high plate edges to assist Resident 27 to scoop food on to her utensil. The CDM stated the facility did not have a scoop plate. The CDM stated the facility had one scoop plate and it broke the previous day. The CDM stated a new scoop plate had been ordered and would arrive in one day. During a concurrent observation and interview on 3/4/25 at 12:31 p.m. with Resident 27 in Resident 27's room, Resident 27 was seen eating lunch with her fingers on a regular plate. Resident 27 stated she typically used a special plate that helped her eat. During an interview on 3/5/25 at 12:02 p.m. with the Director of Staff Development (DSD), the DSD stated kitchen staff were responsible to accurately plate each meal per the meal ticket. The DSD stated Licensed Vocational Nurses (LVN) were responsible to ensure each meal ticket matched the plated dish before it was served to the resident. The DSD stated LVN's checked meal trays before serving to residents to ensure the correct diet, texture and adaptive equipment device were present. During an interview on 3/5/25 at 2:36 p.m. with the Registered Dietician (RD), the RD stated she expected all meal ticket orders to be followed. The RD stated the scoop plate made it easier for Resident 27 to eat. The RD stated Resident 27 was at risk for decreased oral intake if she could not easily eat her meal. During an interview on 3/6/25 at 8:15 a.m. with LVN 2, LVN 2 stated adaptive eating equipment devices were listed on the meal ticket. LVN 2 stated the scoop plate was an adaptive eating equipment device. LVN 2 stated all meals were expected to be served per the meal ticket order. LVN 2 stated the scoop plate helped Resident 27 eat with limited assistance and made it easier to scoop food onto utensils using the raised plate edges. LVN 2 stated Resident 27 was at risk for decreased oral intake or frustration if she could not easily eat her meal. LVN 2 stated LVN's were responsible to ensure meal ticket orders were followed before serving every meal. During an interview on 3/6/25 at 8:53 a.m. with the Administrator (ADM), the ADM stated she expected kitchen staff to plate meals accurately per the meal ticket order. The ADM stated the scoop plate was an adaptive equipment device used for eating. The ADM stated Resident 147's meal should have been plated per the meal ticket order. During an interview on 3/6/25 at 10:14 a.m. with Resident 27, Resident 27 stated it took longer to eat her meal with no scoop plate. Resident 27 stated she preferred the scoop plate because it was easier to eat on. During an interview on 3/6/25 at 11:35 a.m. with Certified Nursing Assistant (CNA) 7, CNA 7 stated Resident 27 used a scoop plate to eat. CNA 7 stated the scoop plate had raised, curved edges that made it easier for Resident 27 to scoop food onto a utensil. CNA 7 stated Resident 27 had limited mobility in her upper extremities and the scoop plate helped her eat with limited assistance. CNA 7 stated Resident 27 was at risk for decreased oral intake, frustration and decreased independence without the scoop plate. During an interview on 3/7/25 at 5:34 p.m. with the Director of Nursing (DON), the DON stated he expected all meal ticket orders to be followed. The DON stated the scoop plate was an adaptive equipment device. The DON stated he expected all kitchen staff to plate meals per the meal ticket order. The DON stated he expected all LVN's to ensure meal ticket orders matched the plated meal before serving to each resident. The DON stated he expected CNA's to identify any plated meal errors when assisting with meal set up. The DON stated Resident 27's meal should have been plated per the meal ticket order on a scoop plate. The DON stated Resident 27 was at risk for decreased oral intake and weight loss if she could not eat her meal. During a review of the facility's job description document titled, Dietary Cook, dated 2023, the document indicated, .ensures appropriate utensils and equipment are provided with the resident's meal tray . During a review of the facility's job description document titled, Dietary Aide, dated 2023, the document indicated, .sets up meal trays, food carts, dining room, etc., as instructed .assists in checking dietary trays before distribution and delivering food carts to designated areas . During a review of the facility's job description document titled, Dietary Manager, dated 2023, the document indicated, .overseeing safe and timely meal preparation, including the provision of meals and/or supplements in accordance with resident's needs, preferences, and care plan .uses forecasts .inventory, and equipment records to plan the purchase of food, supplies, and equipment .processes new diet orders and diet changes. Keeps diet cards updated . During a review of the facility's job description document titled, Certified Nursing Assistant, dated 2023, the document indicated, .coordinates dining room services at assigned mealtimes, including set-up and clean-up, meal tray delivery, feeding assistance, and documentation of meal intake . During a review of the facility's policy and procedure (P&P) titled, Food Safety Requirements, dated 11/2022, the P&P indicated, .Food will also be .distributed and served in accordance with professional standards for food service safety . During a review of the facility's P&P titled, Adaptive Feeding Equipment, dated 11/2024, the P&P indicated, .The dietary department should be notified of resident's needing adaptive feeding equipment; the equipment is stored and maintained in the dietary department. Appropriate utensils should be placed on the resident's food tray, at each meal, and returned to the dietary department, on the food tray, for sanitization .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents were treated with dignity and respect for five of six sampled residents (Residents' 1, 39, 40, 41, and 97) when: 1. LVN 1 administered medications to Residents' 39, 40, 41 and 97 without closing the privacy curtain or the door. 2. Licensed Vocational Nurse (LVN) 2 checked Resident 1's blood sugar level (BS-amount of sugar in the blood) without closing the privacy curtain or the door. These failures resulted in Residents' 1, 39, 40, 41, and 97 not provided respect and dignity during care which could potentially impact residents' well-being leading to vulnerability, decreased dignity, anxiety, stress and depression. Findings: 1. During a concurrent observation and interview on 3/6/25 at 7:55 a.m. in Station 1 East Hall with Licensed Vocational Nurse (LVN) 1, LVN 1 prepared Resident 40's medications and entered Resident 40's room. Resident 40 was lying in bed and inside the room was another resident. LVN 1 administered Resident 40's medications without closing the privacy curtain or the door. LVN 1 stated she did not close the privacy curtain or the door when she administered Resident 40's medications and should have. LVN 1 stated it was a dignity issue. During a review of Resident 40's AR, dated 3/6/25, the AR indicated Resident 40 was re-admitted to the facility on [DATE] with diagnoses which included hypertension, alcoholic cirrhosis (liver is scarred and damaged permanently) and cellulitis (infection of the skin and tissues beneath the skin). During a review of Resident 40's Minimum Data Set (MDS- an assessment tool used to identify resident cognitive[pertaining to reasoning, memory and judgement] and physical functional level), assessment dated [DATE], indicated Resident 40's Brief Interview for Mental Status (BIMS-screening tool used in nursing home to assess cognition) assessment score was 15 out of 15 (0-15 scale [0-6 severe cognitive deficit, 7-12 moderate cognitive deficit, 13-15 no cognitive deficit]) indicating Resident 40 had no cognitive deficit. During a concurrent observation and interview on 3/6/25 at 8:20 a.m. in Station 1 east hall with LVN 1, LVN 1 prepared Resident 39's medications and entered Resident 39's room. Resident 39 was sitting at the edge of the bed playing puzzles and inside the room was another resident. LVN 1 administered Resident 39's medications without closing the privacy curtain or the door. LVN 1 stated she did not close the privacy curtain or the door to give Resident 39 privacy to take her medications and she should have. During a review of Resident 39's admission Record, dated 3/6/25 the AR indicated Resident 39 was admitted to the facility on [DATE] with diagnoses which included atrial fibrillation (irregular heartbeat), hypertensive heart disease (heart problems caused by prolong high blood pressure) and muscle weakness. During a review of Resident 39's MDS assessment dated [DATE]. Resident 39's BIMS score was 15 out of 15 indicating Resident 39 had no cognitive deficit. During a concurrent observation and interview on 3/6/25 at 8:35 a.m. with LVN 2 in Station two, west hall, LVN prepared Resident 41's medications. Resident 41 was sitting at the edge of the bed and inside the room was another resident. LVN 2 administered Resident 41's medications and did not close the privacy curtain and the door. LVN 2 stated she administered Resident 41's medications and did not close the privacy curtain and the door, and she should have. LVN 2 stated it was Resident 41's resident rights and a dignity issue. During a review of Resident 41's AR dated 3/6/25, the AR indicated Resident 41 was admitted to the facility on [DATE] with diagnoses which included back pain, muscle weakness and hypertension. During a review of Resident 41's MDS assessment dated [DATE], indicated Resident 41's BIMS was 15 out of 15 which indicated Resident 41 had no cognitive deficit. During a concurrent observation and interview on 3/6/25 at 8:42 a.m. with LVN 2 in Station two west wing, LVN 2 prepared Resident 97's medications and entered Resident 97's room. Resident 97 was lying in bed. LVN 2 administered Resident 97's medications and did not close the privacy curtain or door. LVN 2 stated she did not close the privacy curtain and door when she administered Resident 97's medications abd she should have. During a review of Resident 97's AR dated 3/6/25, the AR indicated Resident 97 was admitted to the facility on [DATE] with diagnoses which included kidney failure, hyperlipidemia and dementia (progressive state of decline in mental abilities). During a review of Resident 97's MDS assessment dated [DATE], indicated Resident 97's BIMS assessment score was 10 out of 15 indicating Resident 97 had moderate cognitive deficit. During an interview on 3/7/25 at 10 a.m. with the Director of Staff Development (DSD), the DSD stated the practice was to ensure to provide privacy by closing the privacy curtain and or the door during medication administration including checking of blood sugar level. The DSD stated it was a dignity issue and resident rights to their privacy. During a concurrent observation and interview on 3/6/25 at 7:55 a.m. with LVN 1 in Station 1 west hall, LVN 1 prepared Resident 40's medications. LVN 1 entered Resident 40's room, Resident 40 was lying in bed covered with blanket and answered questions. LVN 1 administered medications to Resident 40 without closing the door or closing the privacy curtain. Residents, staff and visitors walking by and could see Resident 40 taking her medications. 2. During a concurrent observation and interview on 3/6/25 at 11:25 a.m. in east hall cart 2 with LVN 2, LVN 2 entered Resident 1's room. Resident 1 was standing next to his bed located closest to the door and inside the room with Resident 1 was another resident. LVN 2 checked Resident 1's blood sugar without closing the privacy curtain or the door, while the other resident watched LVN 2 performed the blood sugar checked to Resident 1. LVN 2 stated she did not close the privacy curtain or the door when he checked Resident 1's blood sugar and soul have. During a review of Resident 1's admission Record (AR) dated 3/17/25, the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which included diabetes mellitus (high blood sugar level in the blood) and hypertension. During a review of Resident 1's MDS assessment dated [DATE], indicated Resident 1's BIMS assessment did not complete assessment, staff was interviewed for Resident 1's mental status which indicated Resident 1's cognitive skill for daily decision making was modified independence. During an interview on 3/7/25 at 2:15 p.m. with LVN 3, LVN 3 stated it was a facility practice to provide privacy by closing the privacy curtain and doors during medication administration. LVN 3 stated it was the responsibility of the nursing staff to ensure privacy was provided during medication administration. LVN 3 stated there are other residents, staff and visitors walking by and could see residents while taking their medications and fingerstick (a procedure . During an interview on 3/7/25 at 5:55 p.m. with the Director of Nursing (DON), the DON stated his expectation was to ensure privacy was provided to residents during medication administration. The DON stated it was a dignity issue. During a review of the facility's policy and procedure (P&P) titled, Resident Rights, dated 2023, the P&P indicated, . The resident has a right to be treated with respect and dignity . During a review of the facility's policy and procedure (P&P) titled, Promoting/Maintaining Resident Dignity, dated 2024, the P&P indicated, . All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights . Maintain resident privacy . During a review of the facility's policy and procedure (P&P) titled, Medication Administration, dated 2024, the P&P indicated, . Knock or announce presence . Provide privacy .|

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement a comprehensive care plan for 10 of 15 sampled residents (Residents 10, 28, 29, 30, 37, 39, 40, 27, 24, and 14) when: 1. Resident's 10, 29, 30, 37, 39, and 40 did not have care plan for enhanced barrier precautions (EBP-infection control strategy, involving use of gowns and gloves during high-contact resident care). These failures placed Residents' 10, 29, 30, 37, 39, and 40 needs not being met. 2. Resident 28 care plan for Enhanced Barrier Precaution (EBP-a set of infection control measures that use personal protective equipment [PPE] to reduce the spread of multidrug-resistant organisms [MDROs]). This failure had the potential for Resident 28's needs being unmet. 3. Resident 27's actives care plan lacked person-centered approach for conversation and socializing. This failure had the potential for missed opportunities for emotional and cognitive stimulation. 4. Resident 24's care plan for impaired cognitive function/dementia was not implemented timely. This failure had the potential for resident 24's needs to not be met and put Resident 24 at an increase for cognitive decline. 5. Resident 14's care plan was not developed to address the use of an anticoagulant (blood thinner) medication. This failure had the potential for Resident 14 to experience severe bruising and bleeding which could lead to serious medical condition and hospitalization. Findings: 1. During a review of Resident 10's admission Record, (AR) dated 3/6/25, the AR indicated Resident 10 was admitted to the facility on [DATE] with diagnoses which included diabetes (high sugar level in the blood), open wound to right knee, open wound to left knee and muscle weakness. During a review of Resident 10's Minimum Data Set (MDS- an assessment tool used to identify resident cognitive[pertaining to reasoning, memory and judgement] and physical functional level), assessment dated [DATE], indicated Resident 10's Brief Interview for Mental Status (BIMS-screening tool used in nursing home to assess cognition) assessment score was 14 out of 15 (0-15 scale [0-6 severe cognitive deficit, 7-12 moderate cognitive deficit, 13-15 no cognitive deficit]) indicating Resident 10 had no cognitive deficit. During a review of Resident 29's admission Record, (AR) dated 3/6/25, the AR indicated Resident 29 was admitted to the facility on [DATE] with diagnoses which included dementia (a progressive state of decline in mental abilities) and diabetes. During a review of Resident 29's MDS assessment dated [DATE], indicated Resident 29's BIMS assessment was not able to complete and staff assessment was conducted which indicated Resident 29 had a score of 2 indicating Resident 29 was moderately impaired, decisions poor and required cues and supervision. During a review of Resident 30's admission Record, (AR) dated 3/6/25, the AR indicated Resident 30 was admitted to the facility on [DATE] with diagnoses which included diabetes, surgical aftercare, and chronic ulcer (wounds that fail to heal within a normal time frame) of left foot. During a review of Resident 30's MDS assessment dated [DATE], indicated Resident 30's BIMS assessment score was 13 out of 15 indicating Resident 30 had no cognitive deficit. During a review of Resident 37's admission Record, (AR) dated 3/6/25, the AR indicated Resident 30 was admitted to the facility on [DATE] with diagnoses which included open wound, non-pressure chronic ulcer (persistent skin wound that fails to heal properly) of right heel and muscle weakness. During a review of Resident 37's MDS assessment dated [DATE], indicated Resident 37's BIMS assessment score was 15 out of 15 indicating Resident 37 had no cognitive deficit. During a review of Resident 39's admission Record, (AR) dated 3/6/25, the AR indicated Resident 39 was admitted to the facility on [DATE] with diagnoses which included cellulitis ( bacterial skin infection of skin and tissues beneath the skin) of left lower limb, diabetes and muscle weakness. During a review of Resident 39's MDS assessment dated [DATE], indicated Resident 39's BIMS assessment score was 15 out of 15 indicating Resident 39 had no cognitive deficit. During a review of Resident 40's admission Record, (AR) dated 3/6/25, the AR indicated Resident 28 was admitted to the facility on [DATE] with diagnoses which included cellulitis of unspecified part of limb and pressure ulcer of sacral region. During a review of Resident 40's MDS assessment dated [DATE], indicated Resident 40's BIMS assessment score was 15 out of 15 indicating Resident 40 had no cognitive deficit. During a concurrent interview and record review on 3/5/25 at 3:50 p.m. with the IP, Resident's 10, 29, 30, 37, 39, and 40's clinical record were reviewed. The IP stated Resident's 10, 29, 30, 37, 39 and 40 did not have care plans for the EBP. The IP stated care plan should have been initiated as soon as Residents' 10, 29, 30, 37, 39 and 40 were placed on EBP. The IP stated care plan directs staff to care for resident needs. The IP stated all licensed nurses were responsible in creating care plan and she was responsible in creating care plan for residents on EBP. During an interview on 3/7/25 at 10:30 a.m. with Director of Staff Development (DSD), the DSD stated care plan are the responsibilities of licensed nurse. The DSD stated licensed nurses are capable of creating care plan. The DSD stated EBP care plan should have been initiated right away when resident was placed on EBP. During an interview on 3/7/25 at 3:45 p.m. with Licensed Vocational Nurse (LVN)1, LVN 1 stated care plan are the responsibility of licensed nurse. LVN 1 stated the IP and DON are responsible in creating EBP care plan to direct staff to care for resident. During an interview on 3/7/25 at 6:15 p.m. with the Director of Nursing (DON), the DON stated the IP was responsible in identifying residents belonging in the EBP and notifying staff of the precautions needed to care for residents. The DON stated care plan should be complete and patient centered. The DON stated IP was responsible in creating care plan and should have initiated care plan right away as soon as resident were determined to be on EBP. During a review of facility's policy and procedure (P&P) titled, Comprehensive Care Plans, dated 2025, the P&P indicated, . 2. The comprehensive care plan will be developed within 7 days . The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished . b. Any services that would otherwise be furnished . 6. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment . During a review of facility's policy and procedure (P&P) titled, Enhanced Barrier Precaution, dated 2025, the P&P indicated, . All staff receive training on enhanced barrier precautions upon hire and annually .An order for enhanced barrier precaution will be obtained for residents with any of the following: i. Wounds [ . chronic wounds such as pressure ulcer . urinary catheters . During a review of facility document titled, Infection Preventionist, Job Description dated 2023, the document indicated, . Establishes facility-wide systems for the prevention, identification, reporting, investigation, and control of infections and communicable diseases . Maintains documentation of infection prevention and control program activities . 5. During a review of Resident 14's admission Record (AR- document containing resident personal information), dated 3/6/25, the AR indicated, Resident 14 was admitted to the facility on [DATE], with diagnoses which included other nondisplaced fracture of sixth cervical vertebra, subsequent encounter for fracture with routine healing (a break in the sixth bone of the neck where fractured pieces of bone have not moved out of alignment and the fractures healing process is progressing normally with routine care), chronic systolic congestive heart failure (a condition where the left ventricle of the heart is weakened, resulting in reduced pumping ability and fluid buildup in the lungs and other parts of the body), chronic obstructive pulmonary disease (lung disease causing restricted airflow and breathing problems), unspecified bilateral primary osteoarthritis of hip (a degenerative condition where the cartilage in both hip joints is breaking down, causing pain and stiffness), and muscle weakness generalized. During a review of Resident 14's Minimum Data Set (MDS- a resident assessment tool) assessment, dated 2/19/25, the MDS assessment indicated Resident 14's Brief Interview for Mental Status (BIMS- an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) assessment score was 13 out of 15 which indicated Resident 14 had no cognitive deficit (a decline in thinking abilities, like memory, reasoning, and problem-solving). During a review of Resident 14's Order Summary Report, dated 3/6/25, the Order Summary Report indicated, Resident 14 had an active order for .Apixaban Oral Tablet 2.5 [milligrams (MG)- a unit of measurement used to measure the dosage of medication] (Apixaban [ a type of medicine known as an anticoagulant. It decreases the clotting ability of the blood and helps prevent harmful blood clots from forming]) .for anticoagulant. The Order Summary Report indicated .order status active .order date 2/13/25 .start date 2/14/25 . During a review of Resident 14's Care Plan, dated 3/6/25, the Care Plan indicated, Resident 14 did not have an anticoagulant care plan. During an interview on 3/6/25 at 8:15 a.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated anticoagulant medications were expected to be care planned. LVN 2 stated it was expected all care plans were person centered and included current treatments. LVN 2 stated care plans ensured members of the healthcare team provided ongoing monitoring of medication side effects. LVN 2 stated Resident 14 was at risk for uncontrolled bleeding if she was injured and was not monitored. During a concurrent observation and interview on 3/6/25 at 2:31 p.m. with Resident 14 in Resident 14's room, Resident 14 was observed lying in bed. Resident 14 stated she had not received anticoagulant education since admitted to the facility. Resident 14 stated she was not aware of any side effects or complications of anticoagulant medication to monitor for. During a concurrent interview and record review on 3/6/25 at 2:34 p.m. with LVN 1, Resident 14's Order Summary Report (OSR), Medication Administration Record (MAR) and Care Plan, dated 3/6/25 were reviewed. LVN 1 stated Resident 14 had received .Apixaban .2.5 MG .two times a day for anticoagulant . since 2/14/25. LVN 1 stated Apixaban was an anticoagulant. LVN 1 stated anticoagulants were a blood thinner, and Resident 14 could bruise easily and have uncontrolled bleeding if injured. LVN 1 could not locate an anticoagulant care plan for Resident 14. LVN 1 stated a care plan must be in place for all residents to address the use of an anticoagulant. LVN 1 stated it was important the care plan reflected the use of an anticoagulant to ensure education and monitoring interventions were in place. LVN 1 stated the care plan purpose was to reflect each residents' current conditions and alert staff to individualized treatment, side effects, and monitoring precautions. During an interview on 3/6/25 at 2:40 p.m. with the Director of Nursing (DON), the DON stated all care plans were expected to reflect the residents needs and active orders to ensure appropriate monitoring precautions and goals were in place, per facility policy. The DON stated Apixaban was an anticoagulant and all anticoagulants were expected to be care planned. The DON stated it was expected Resident 14 had an anticoagulant care plan to ensure she was being monitored by all members of the healthcare team. The DON stated a care plan ensured continuing education was provided to the resident regarding anticoagulation therapy. The DON stated without an anticoagulant care plan Resident 14 was not being monitored by all members of the healthcare team and was at risk for bruising and uncontrolled internal bleeding. The DON stated it was important all members of the healthcare were aware Resident 14 was on an anticoagulant to accurately reflect her needs, goals, and interventions. The DON stated it was important each resident had a personalized and individualized care plan. During a review of the facility's job description document titled, Charge Nurse, dated 2023, the document indicated, .Initiates, reviews and updates care plans as required . During a review of the facility's policy and procedure (P&P) titled, Baseline Care Plan, undated, the P&P indicated, .The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective person-centered care of the resident that meet professional standards of quality of care .The baseline care plan will .include the minimum healthcare information necessary to properly care for a resident including, but not limited to .physician orders . The admitting nurse, or supervising nurse .shall gather information from the admission physical assessment .physician orders, and discussion with the resident . interventions shall be initiated that address the resident's current needs including . any identified needs for supervision .a written summary of the baseline care plan shall be provided to the resident .the summary shall include, at a minimum .a summary of the resident's medications. During a review of the facility's P&P titled, Comprehensive Care Plans, undated, the P&P indicated, .It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with residents rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and all services that are identified in the resident's comprehensive assessment and meet professional standards of quality .the comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress . 2. During observation on 3/4/25 at 10:46 a.m. of resident 28's room, resident 28 was not in facility. Resident 28 had Enhanced Barrier precautions (EBP) sign on the door and a dot next to her name. During record review on 3/4/25 at 4:19 p.m. Resident 28's admission note dated 5/22/24 stated resident had bilateral nephrostomy tubes (a thin, flexible catheter that drains urine from the kidney into a bag outside the body). During a concurrent observation and interview on 3/5/24 at 10:19 a.m. with Resident 28, in Resident 28's room, Resident 28 was observed lying in bed watching television (TV) in her gown. Resident 28 stated she had her nephrostomy tube removed on 3/4/25. Resident 28 stated that she has a surgical site from the procedure. During a concurrent interview and record review on 3/7/25 at 10:11 a.m. with Licensed Vocational Nurse (LVN) 3, Resident 28's Care Plan dated 3/6/25 indicated EBP was initiated on 3/6/25. LVN 3 Stated this was not an appropriate timeframe. LVN 3 stated that care plans are important to provide specific care to that person. During review of Resident 28's Care Plan, dated 3/6/25, the Care Plan indicated, Resident 28 EBP care plan was created on 3/6/25. During interview on 3/7/25 at 3:11 p.m. with Infection Preventionist (IP), the IP stated EBP is determined by the IP. The IP stated EBP are for wounds, catheters, and EBP are important for residents who are at an increased risk for infection. The IP stated it is her responsibility to obtain an order and created the EBP care plan right away. The IP stated the resident 28 did not have a care plan for EBP prior to survey. During an interview on 3/7/25 at 5:40 p.m. with the Director of Nurses (DON), The DON stated the expectation for care plans to be completed and resident centered. DON stated admission care plan are to be completed within 14 days. During a review of facility's job description document titled, Infection Preventionist, dated 2023, the document indicated, .Oversees resident care activities that increase risk infection .use and care of .catheter, wound care, incontinence care .remains current on new developments related to infection prevention .servers as resource for staff regarding infection prevention During a review of the facilities policy and procedure P&P titled, Enhanced barrier precautions dated 2024, the P&P indicated, . an order for enhanced barrier precautions will be obtained for residents with . Unhealed surgical wounds .and or indwelling medical devices . 3. During a review of Resident 27's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), indicated Resident 27 was admitted to the facility on [DATE] with a diagnoses absence of left below knee, and blindness, both eyes During a concurrent observation and interview on 3/5/25 at 10:34 a.m. with Resident 27, in Resident 27's room, Resident 27 was lying in bed with cell phone in hand. Resident 27 stated she use to go to actives in the dining room until she got sick. Resident 27 stated she liked to talk to people, she liked to order online. Resident 27 stated she liked to listen to the TV with her roommate. During a concurrent interview and record review on 3/6/25 at 2:57 p.m. with the Activities director (AD), Resident 27's Care plan Room visit/ .activity participation record and Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 1/17/25 the MDS section F -Preferences for Routine and Activities were reviewed. The AD stated she is responsible for progress notes, care plans, and evaluations. The AD stated Resident 27 is a 1:1 room visit, and each visit is 15 minutes long. The AD stated Resident 27 enjoyed localizing in the large dining hall, talking during the room visits and liked to place online orders. The AD stated Resident 27's activity record and care plan were not person centered or individualized. The AD stated it is important Resident 27's activity record and care plan reflect her interests for her mental, emotion and physical health. During an interview on 3/7/25 at 5:40 p.m. with the Director of Nurses (DON), The DON stated the expectation for care plans to be completed and resident centered. DON stated admission care plan are to be completed within 14 days. During a review of the facility's job description document titled, Activities Director, dated 2023, the document indicted, .Contributing to the .care plan .and approaches that are individualized to match the skills, abilities, and interest/preferences of each resident .activities are to be tailored to the resident's unique requirements and skills . During the review of the facilities policy and procedure (P&P) titled, Comprehensive Care Plans, undated, the P&P indicated, . It's the policy of this facility to develop and implement a comprehensive person centered care plan for each resident, consistent with the residents rights, that includes measurable objectives and time frames to meet residents medical, nursing and mental and psychosocial needs and all services that are indicated in the resident's comprehensive assessment and meet professional standards of quality . the comprehensive care plan will include measurable objectives and time frames to meet the residents need as identified in the residence comprehensive assessment . 4. During a Review of Resident 24's admission Record (AR- document containing residents personal information), dated 3/6/25, the AR indicated, Resident 24 was admitted to the facility on [DATE], with diagnoses Type 2 Diabetes Mellitus (when the blood sugar levels in the body are too high), Bipolar Disorder (chronic mental health condition characterized by significant and persistent shifts in mood, energy and activity levels), Unspecified Dementia (a diagnosis used when a person has cognitive decline that cannot be attributed to a specific type of dementia). During a review of Resident 24's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 1/31/25, the MDS section C indicated, Resident 24 had a Brief Interview for Mental Status (BIMS-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 6, (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which suggested Resident 24 severe cognitive impairment. During an observation on 3/4/25 at 10:05 a.m. Resident 24 was sitting in his wheelchair next to a window with light shinning in. During an interview on 3/5/25 at 12:26 p.m. with Resident 24's Family Member (FM) 1, FM 1 stated Resident 24 needs a lot of care, he gets confused. During a concurrent interview and record review on 3/7/25 at 10:11 a.m. with LVN 3, Resident 24's admission Record and Care Plan, dated 3/7/25 were reviewed. LVN 3 stated Resident 24 was admitted with a diagnosis of dementia, and Resident 24 needs to be redirected with his care. LVN 3 stated Resident 24's Impaired cognitive function/dementia Care plan, dated 10/14/24, indicated care plan was created late. LVN 3 stated nurses are responsible to create a care plan. LVN 3 stated care plans are important to know how to care for the resident. During an interview on 3/7/25 at 5:40 p.m. with the DON, the DON stated admission care plans are done by nurses and within 14 days. DON stated a care plan ensures appropriate resident centered care. During a review of the facility's policy and procedure (P&P) titled, Baseline Care Plan, undated, the P&P indicated, .The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective person-centered care of the resident that meet professional standards of quality of care .The admitting nurse, or supervising nurse .shall gather information from the admission physical assessment .and discussion with the resident .A supervising nurse shall verify within 48 hours that a baseline care plan has been developed . During the review of the facilities policy and procedure (P&P) titled, Comprehensive Care Plans, undated, the P&P indicated, . It's the policy of this facility to develop and implement a comprehensive person centered care plan for each resident, consistent with the residents rights, that includes measurable objectives and time frames to meet residents medical, nursing and mental and psychosocial needs and all services that are indicated in the resident's comprehensive assessment and meet professional standards of quality . the comprehensive care plan will include measurable objectives and time frames to meet the residents need as identified in the residence comprehensive assessment .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure services provided met professional standards of practice of quality for eight of nine sampled residents (Resident 12, 10, 30, 39, 40, 29, 37 and 28) when: 1. Resident 12 had a physician's order for a low air loss machine (a medical device used primarily to prevent or treat pressure ulcer (bedsores) and was not provided to Resident 12 and was unplugged. This failure resulted for Resident 12 not receiving the necessary care which could lead to development of pressure ulcer. 2. Resident 10, 30, 39, 40, 29, 37, and 38 needed Enhanced Barrier Precaution (EBP- an infection control measures to reduce the risk of transmission of infections) and the Infection Preventionist (IP) did not get a physician's order, did not perform a wound assessment and did not initiate a care plan (a personalized, structured document used to outline the care and treatment the residents needs). This failure placed Resident 10, 30, 39, 40, 29, 37, and 38 at increased risk for widespread transmission of infections which could lead to serious health complications. Findings: 1. During a concurrent observation and interview on 3/5/25 at 9:40 a.m. in Resident 12's room, Resident 12 was seen lying in bed, covered with blanket and yelling out. Resident 12 did not answer questions asked. Resident 12's bed was positioned in lowest position and had a low air loss mattress. Resident 12's low air loss mattress was turned off and was unplugged from the wall. During a review of Resident 12's admission Record, (AR) dated 3/6/25, the AR indicated Resident 12 was re-admitted to the facility on [DATE] with diagnoses which included hemiplegia (total paralysis of the arm, leg, and trunk of the same side of the body) and hemiparesis (is a condition characterized by weakness or paralysis) dementia (the loss of thinking, remembering, and reasoning) and muscle weakness. During a review of Resident 12's Minimum Data Set (MDS- an assessment tool used to identify resident cognitive[pertaining to reasoning, memory and judgement] and physical functional level), assessment dated [DATE], indicated Resident 12's Brief Interview for Mental Status (BIMS-screening tool used in nursing home to assess cognition) assessment score was 10 out of 15 (0-15 scale [0-6 severe cognitive deficit, 7-12 moderate cognitive deficit, 13-15 no cognitive deficit]) indicating Resident 12 had moderate cognitive deficit. During a review of Resident 12's Order Summary Report, dated 3/6/25 indicated, . low air loss mattress r/t [related to] limited mobility . During a concurrent observation and interview on 3/5/25 at 9:42 a.m. with Certified Nurse Assistant (CNA) 1, CNA 1 stated she was familiar with Resident 12's care. CNA 1 checked the low air loss machine and found it turned off and unplugged. CNA 1 stated The machine was supposed to be on at all times when a resident has an order to prevent skin breakdown. During an interview on 3/5/25 at 9:50 a.m. with Licensed Vocational Nurse (LVN)1, LVN 1 stated she was Resident 12's nurse. LVN 1 stated Resident 12's had a physician's order for low air loss mattress, and it should have been on at all times to prevent pressure ulcer. LVN 1 stated it was the responsibility of the nursing staff to ensure the low air loss mattress machine was on at all times. During an interview on 3/7/25 at 5:55 p.m. with the Director of Nursing (DON), the DON stated his expectation was for the low air loss machine to be on at all times when resident was in bed to prevent skin breakdown. The DON stated it was the responsibility of the nursing staff to ensure the low air loss machine was on and functioning properly. The DON stated not having the low air machine on put Resident 12 at risk of developing skin ulcer. During a review of the professional reference from https://www.ncbi.nlm.nih.gov/books/NBK333135/ undated, indicated, The Prevention and Management of Pressure Ulcers in Primary and Secondary Care. Pressure redistributing devices. Pressure relieving and redistributing devices are widely accepted methods of trying to prevent the development of pressure ulcers for people considered as being at risk. The devices used include different types of mattresses, overlays, cushions and seating. These devices work by reducing or redistributing pressure, friction or shearing forces . 2. During a review of Resident 10's admission Record, (AR) dated 3/6/25, the AR indicated Resident 10 was admitted to the facility on [DATE] with diagnoses which included diabetes (high sugar level in the blood), open wound to right knee, open wound to left knee and muscle weakness. During a review of Resident 10's Minimum Data Set (MDS- an assessment tool used to identify resident cognitive[pertaining to reasoning, memory and judgement] and physical functional level), assessment dated [DATE], indicated Resident 10's Brief Interview for Mental Status (BIMS-screening tool used in nursing home to assess cognition) assessment score was 14 out of 15 (0-15 scale [0-6 severe cognitive deficit, 7-12 moderate cognitive deficit, 13-15 no cognitive deficit]) indicating Resident 10 had no cognitive deficit. During a review of Resident 28's admission Record, (AR) dated 3/6/25, the AR indicated Resident 28 was re-admitted to the facility on [DATE] with diagnoses which included retention of urine, hemiplegia and hemiparesis and muscle weakness. During a review of Resident 28's MDS assessment dated [DATE], indicated Resident 28's BIMS assessment score was 15 out of 15 indicating Resident 28 had no cognitive deficit. During a review of Resident 29's admission Record, (AR) dated 3/6/25, the AR indicated Resident 29 was admitted to the facility on [DATE] with diagnoses which included dementia (a group of symptoms that affects memory, thinking and social abilities) and diabetes [a chronic medical condition that affects how the body process sugar]. During a review of Resident 29's MDS assessment dated [DATE], indicated Resident 29's BIMS assessment was not able to complete and staff assessment was conducted which indicated Resident 29 had a score of 2 indicating Resident 29 was moderately impaired, decisions poor and required cues and supervision. During a review of Resident 30's admission Record, (AR) dated 3/6/25, the AR indicated Resident 30 was admitted to the facility on [DATE] with diagnoses which included diabetes, surgical aftercare, and chronic ulcer of left foot. During a review of Resident 30's MDS assessment dated [DATE], indicated Resident 30's BIMS assessment score was 13 out of 15 indicating Resident 30 had no cognitive deficit. During a review of Resident 37's admission Record, (AR) dated 3/6/25, the AR indicated Resident 30 was admitted to the facility on [DATE] with diagnoses which included open wound, non-pressure chronic ulcer of right heel and muscle weakness. During a review of Resident 37's MDS assessment dated [DATE], indicated Resident 37's BIMS assessment score was 15 out of 15 indicating Resident 37 had no cognitive deficit. During a review of Resident 39's admission Record, (AR) dated 3/6/25, the AR indicated Resident 39 was admitted to the facility on [DATE] with diagnoses which included cellulitis of left lower limb, diabetes and muscle weakness. During a review of Resident 39's MDS assessment dated [DATE], indicated Resident 39's BIMS assessment score was 15 out of 15 indicating Resident 39 had no cognitive deficit. During a review of Resident 40's admission Record, (AR) dated 3/6/25, the AR indicated Resident 28 was admitted to the facility on [DATE] with diagnoses which included cellulitis of unspecified part of limb and pressure ulcer of sacral region. During a review of Resident 40's MDS assessment dated [DATE], indicated Resident 40's BIMS assessment score was 15 out of 15 indicating Resident 40 had no cognitive deficit. During a concurrent interview and record review on 3/5/25 at 3:23 p.m. with IP, IP stated she had been the IP in the facility for over a year. The IP stated her role includes monitoring infection control and antibiotic use. The IP stated there are seven residents on EBP. The IP stated all seven residents on EBP did not have physician's orders. The IP stated according to facility policy and procedure, she should have placed the physician's order on the day Residents' 10, 30, 39, 40, 29, 37 and 28 were placed on EBP. The IP stated Residents' 10, 30, 39, 40, 29, 37 and 28 did not have EBP care plans and should have. The IP stated care plans should be started within 24 hours. The IP stated she did not complete assessment or documentation for the residents' wounds. The IP stated as a result she did not know whether resident wounds were improving or getting worse because there was documentation. During an interview on 3/7/25 at 6:05 p.m. with the Director of Nursing (DON), the DON stated the IP was responsible in identifying residents belonging in the EBP and notifying staff of the precautions needed to care for residents. The DON stated physician order was needed as soon as a resident was placed on EBP. The DON stated the IP should have called Medical Doctor (MD) and get the order. The DON stated his expectation was for the IP to do her job. During a review of facility document titled, Infection Preventionist, Job Description dated 2023, the document indicated, . Establishes facility-wide systems for the prevention, identification, reporting, investigation, and control of infections and communicable diseases . Maintains documentation of infection prevention and control program activities . During a review of the professional reference from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/faqs.html undated, indicated, Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). Implementation of Enhanced Barrier Precautions . 19. If a nursing home is receiving a resident known to be colonized with a MDRO from an acute care hospital, do they need to continue Contact Precautions in the facility, or can Enhanced Barrier Precautions be used? The resident should be maintained on Contact Precautions in the nursing home if he or she has acute diarrhea, draining wounds, or other sites of secretions or excretions that are unable to be covered or contained or for a limited period of time during a suspected or confirmed MDRO outbreak investigation. If none of these are present, Enhanced Barrier Precautions would typically be appropriate for the management of this resident, unless otherwise directed by public health authorities . 23. The guidance describes that all residents with wounds would meet the criteria for Enhanced Barrier Precautions. What is the definition of a wound in relation to this guidance? In the guidance, wound care is included as a high-contact resident care activity and is generally defined as the care of any skin opening requiring a dressing. However, the intent of Enhanced Barrier Precautions is to focus on residents with a higher risk of acquiring an MDRO over a prolonged period of time. This generally includes residents with chronic wounds, and not those with only shorter-lasting wounds, such as skin breaks or skin tears covered with a Band-aid or similar dressing. Examples of chronic wounds include, but are not limited to, pressure ulcers, diabetic foot ulcers [are open sores that typically develop on the feet of individuals with diabetes [a chronic medical condition that affects how the body process sugar], and chronic venous stasis ulcers [wound develops on the lower leg as a result of poor blood circulation]. Ostomies [a surgical opening in the body to allow waste to exit], such as colostomies or ileostomies, are not defined as a wound for Enhanced Barrier Precautions .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the facility medication error rate did not exceed five percent. The facility's medication error was 6.9%. 1. Licensed Vocational Nurse (LVN) 1 did not follow medication direction when she administered lactulose solution (medication used to treat constipation) to Resident 40. This failure resulted for Resident 40 not receiving the full therapeutic benefit of the prescribed lactulose solution (medication used to treat constipation) which could lead to constipation or serious health condition. 2. LVN 1 administered metformin (medication used to treat diabetes) medication without food and did not follow the physician's order to administer with food. This failure had the potential risk for Resident 39 to experienced gastrointestinal upset (GI-gastric upset like diarrhea) and could decrease the absorption of Metformin leading to less effective blood sugar control. Findings: 1. During a concurrent medication administration pass observation and interview on 3/6/25 at 8:05 a.m. at the east hall, LVN 1 was preparing Resident 40's medications and poured lactulose solution in a clear medication cup. LVN 1 administered Resident 40's medications. LVN 1 stated she did not administer 30 ml (milliliter-unit of measurement) of lactulose as ordered. LVN 1 stated she should have administered 30 ml. as ordered but instead administered 20 ml to Resident 40. LVN 1 stated Resident 40 did not received the whole medication dose as ordered by MD which could lead to constipation. During a review of Resident 40's admission Record, dated 3/6/25, the admission record indicated Resident 40 was re-admitted to the facility on [DATE] with diagnoses which included alcoholic cirrhosis of liver (permanent scarring of the liver), duodenal ulcer (sore that developed in the lining of the first part of the small intestine) and unsteadiness on feet. During a review of Resident 40's Order Summary Report, (OSR) dated 3/6/25, the OSR indicated, . Lactulose Oral Solution 10GM [gram- unit of measurement]/15ML [milliliter-unit of measurement] (Lactulose) Give 30ml by mouth three times a day . During an interview on 3/7/25 at 9:18 a.m. with LVN 2, LVN 2 stated it was important to follow medication order when administering medications to residents. LVN 2 stated administering medication less than the ordered amount was under dosing and does not help resident. During an interview on 3/7/25 at 10:25 a.m. with the Director of Staff Development (DSD), the DSD stated it was important to follow medication order and give the correct amount of medication as ordered by medical doctor (MD) to be effective. The DSD stated the practice was to administer the correct amount of medication as ordered to be effective. During an interview on 3/7/25 at 5:55 p.m. with the Director of Nursing (DON), The DON stated licensed nurse should have followed the medication order and measured the correct amount of lactulose for Resident 40. The DON stated failing to administer the correct dosage could result in the medication not reaching the required potency. 2. During a concurrent medication administration pass observation and interview on 3/6/25 at 8:15 a.m. at east wing medication cart 1, LVN 1 prepared Resident 39's medications. LVN 1 administered Resident 39's medications without food. LVN 1 stated the medication direction was to administer metformin with food. LVN 1 stated she did not give food to Resident 39 when she administered the metformin. LVN stated the metformin given on an empty stomach could cause GI distress. During a review of resident 39's admission Record, dated 3/6/25, the admission record indicated Resident 39 was admitted to the facility on [DATE] with diagnoses which included diabetes (high blood sugar level in the blood), anemia (body does not have enough healthy red blood cells) and muscle weakness. During a review of Resident 39's Order Summary Report, (OSR) dated 3/6/25, the OSR indicated, . metformin HCl [brand name] [hydrochloride] Oral 500MG [milligram-unit of measurement] Give one [1] tablet by mouth two times a day for Give with meals . During an interview on 3/7/25 at 2:05 p.m. with LVN 3, LVN 3 stated the practice was to always follow the medication order and directions when administering medications. LVN 3 stated if the medication order includes a direction to give with food, it should be followed. LVN 3 stated medications requiring food should be given while the resident was eating, or a snack should be provided if resident was not eating to prevent GI discomfort. During an interview on 3/7/25 at 5:55 p.m. with the Director of Nursing (DON), the DON stated his expectation was for the licensed nurse to administer metformin while resident was eating. The DON stated licensed nurse could have offered a snack with the metformin after Resident 39 finished eating to avoid gastrointestinal upset and ensure proper medication absorption. During a review of the facility's policy and procedure (P&P) titled, Medication Administration, dated 11/24, the P&P indicated, .Ensure the that the six rights of medication administration are followed: . Right dose . Administer medication as ordered . Provide appropriate amount of food and fluid . During a review of the facility's policy and procedure (P&P) titled, Medication Error, dated 11/24, the P&P indicated, . Medication administered not in accordance with the prescriber's order . Incorrect dose, route of administration, dosage form . Administering medications without adequate fluids, without food or antacids .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to implement and maintain an effective infection prevention and control program to prevent the transmission of infection for 11 out of 11 sampled residents (Residents' 8, 9, 23, 24, 26, 33, 35, 39, 41, 44, and 97) when nursing staff did not provide or assist residents in performing hand hygiene before they were served their lunch tray. This failure to provide hand hygiene placed Residents' 8, 9, 23, 24, 26, 33, 35, 39, 41, 44, and 97 at increased risk for cross contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect). Findings: During an observation on 3/4/25 at 11:50 a.m. during meal observation in the dining room. Residents' 8, 9, 23, 24, 26, 33, 35, 39, 41, 44, and 97 were seen assisted by staff for lunch and staff placed apron on a couple residents. Staff distributed lunch trays to residents and did not provide or offered hand hygiene to residents eating in the dining room. During a review of Resident 8's Minimum Data Set (MDS-a resident assessment tool used to identify resident cognitive, physical abilities and needs) assessment dated [DATE], the MDS assessment indicated Resident 8's Brief Interview for Mental Status (BIMS-screening tool used to assess resident cognition status) 0-15 scale (0-6 severe cognitive deficit, 7-12 moderate cognitive deficit, 13-15 no cognitive deficit) assessment score was 8 out of 15 which indicated Resident 8 had moderate cognitive deficit. During a review of Resident 9's MDS assessment dated [DATE], the MDS assessment indicated Resident 9's BIMS assessment score was 11 out of 15 which indicated Resident 9 had moderate cognitive deficit. During a review of Resident 23's MDS assessment dated [DATE], the MDS assessment indicated Resident 23's BIMS assessment score was 7 out of 15 which indicated Resident 23 had moderate cognitive deficit. During a review of Resident 24's MDS assessment dated [DATE], the MDS assessment indicated Resident 24's BIMS assessment score was 6 out of 15 which indicated Resident 24 had severe cognitive deficit. During a review of Resident 26's MDS assessment dated [DATE], the MDS assessment indicated Resident 26's BIMS assessment score was 4 out of 15 which indicated Resident 26 had severe cognitive deficit. During a review of Resident 33's MDS assessment dated [DATE], the MDS assessment indicated Resident 33's BIMS assessment score was 10 out of 15 which indicated Resident 33 had moderate cognitive deficit. During a review of Resident 35's MDS assessment dated [DATE], the MDS assessment indicated Resident 35's BIMS assessment score was 5 out of 15 which indicated Resident 35 had severe cognitive deficit. During a review of Resident 39's MDS assessment dated [DATE], the MDS assessment indicated Resident 39's BIMS assessment score was 15 out of 15 which indicated Resident 39 had no cognitive deficit. During a review of Resident 41's MDS assessment dated [DATE], the MDS assessment indicated Resident 41's BIMS assessment score was 15 out of 15 which indicated Resident 41 had no cognitive deficit. During a review of Resident 44's MDS assessment dated [DATE], the MDS assessment indicated Resident 44's BIMS assessment score was 3 out of 15 which indicated Resident 44 had severe cognitive deficit. During a review of Resident 97's MDS assessment dated [DATE], the MDS assessment indicated Resident 97's BIMS assessment score was 10 out of 15 which indicated Resident 97 had moderate cognitive deficit. During an interview on 3/4/25 at 12:15 p.m. with Certified Nurse Aide (CNA) 8, CNA 8 stated she assisted residents in the dining room for meals but did not provide hand hygiene to residents before serving their lunch tray. CNA 8 stated she should have offered and provided hand hygiene to residents because it was an infection prevention and avoid stomach issues. CNA 8 stated she did not know what activities the residents were doing before they had lunch. During an interview on 3/4/25 at 12:30 p.m. with CNA 9, CNA 9 stated, All residents in the dining room were not provided hand hygiene prior to them eating lunch. CNA 9 stated staff should have offered and provided residents hand hygiene before residents were served lunch. CNA 9 stated residents should have been provided hand hygiene to prevent GI upset (gastrointestinal-discomfort or dysfunction in the gastrointestinal tract). During an interview on 3/5/25 at 12:35 p.m. with Activities Assistant (AA), the AA stated several residents participated activities in the dining room before lunch was served. The AA stated activities involved touching papers, tables and other residents. The AA stated residents did not washed or cleaned their hands after activity and before lunch. The AA stated she did not provide hand hygiene to residents after activity. The AA stated she should have provided and offered hand hygiene to residents to prevent cross contamination and stomach upset. During an interview on 3/7/25 at 9:25 a.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated residents should be offered and assisted with hand hygiene before residents are served meals. LVN 2 stated it was the responsibility of the staff to ensure hand hygiene are provided to residents before each meal for infection prevention and control and prevent GI upset. During an interview on 3/7/25 at 10:25 a.m. with the Director of Staff Development (DSD), the DSD stated CNAs prepares residents before meals. The DSD stated residents are provided with hand wipes for independent residents and staff helped dependent residents with their hand hygiene to prevent GI upset. During an interview on 3/7/25 at 5:55 p.m. with the Director of Nursing (DON), the DON stated his expectation was for nursing staff, To ensure resident's hands are cleaned and properly positioned and placed in the dining room. The DON stated it was a sanitation issue which could cause GI problem. During a review of facility's policy and procedure (P&P) titled, Infection Prevention and Control Program, dated 2024, the P&P indicated, . All staff are responsible for following all policies and procedures related to the program . All staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted . Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedure . During a review of the facility's job description document titled, Dietary Aide, dated 2023, the document indicated, . follows appropriate safety and hygiene measures at all times to protect residents .follows established infection control policies and procedures .as a condition of employment, completes all assigned training and skills competency .maintains food storage areas in a clean and properly arranged manner at all times .assists in inventory and storing in-coming food, supplies, etc., as necessary .

Based on observation, interview, and record review, the facility failed to ensure food and ice were stored, prepared, and served safely in accordance with professional standards for food service safety for 44 out of 44 residents at the facility when: 1. Honey mustard packets ready for residents' use were expired. 2. Honey mustard packets and frozen sausage pizza toppings were not labeled. 3. A dietary aides personal belonging was observed on the kitchen spice preparation rack. 4. The ice machine water pump (a compartment within the ice machine that carries water) was observed with black spots. These failure resulted to unsafe food handling practices which had the potential risk to caused cross contamination (occurs when harmful bacteria are transferred from one surface or food to anther) and foodborne illness (occurs when a person consume contaminated food or beverages) for the 44 residents at the facility. Findings: 1. During a concurrent observation and interview on 3/4/25 at 9:32 a.m. with the Certified Dietary Manager (CDM) in the kitchen dry storage room, a brown box filled with individual honey mustard packets was observed to have a use by date (is the last date recommended for the consumption of a product while its at its best quality) of 1/15/25. The CDM stated the individual honey mustard packets were expired per the use by date of 1/15/25 on the brown box. The CDM stated it was the responsibility of the entire kitchen staff to identify expired food items in the kitchen. The CDM stated all expired food items were expected to be removed from the kitchen. The CDM stated she completed kitchen rounds twice a week. The CDM stated the individual honey mustard packets should have been identified during kitchen rounds and removed. 2. During a concurrent observation and interview on 3/4/25 at 9:32 a.m. with the CDM in the kitchen dry storage room, a brown box filled with individual honey mustard packets was observed to have no open date (refers to the date a product was opened or first used). The CDM could not locate an open date on the box. During an observation with the CDM in the kitchen freezer, frozen sausage pizza topping was observed with no receive date, open date, or use by date. The CDM could not determine the received date, open date, or use by date on the frozen sausage pizza topping. The CDM stated all food items were expected to have a label with the receive date, open date, and use by date. The CDM stated it was the responsibility of the entire kitchen staff to label food items with the receive date, open date, and use by date. The CDM stated it was the responsibility of the entire kitchen staff to identify food items that were not labeled correctly. The CDM stated she completed kitchen rounds twice a week and reviewed food items for accurate labeling. The CDM stated food items were labeled with receive date, open date, and use by dates to prevent the use of expired food items when cooking or serving food to residents. The CDM stated residents were at risk for foodborne illness is they ate expired honey mustard packets or frozen sausage pizza topping. During an interview on 3/5/25 at 2:36 p.m. with the Registered Dietician (RD), the RD stated she completed monthly kitchen rounds to ensure food items were stored, prepared, distributed and served in accordance with professional standards for food safety. The RD stated the most recent kitchen audit was approximately two weeks ago but could not state the exact date. The RD stated she used the Department of Health and Human Services Centers for Medicare and Medicaid Services, Kitchen/Food Service Observation form to complete monthly kitchen rounds. The RD stated she did not identify the individual honey mustard packets or frozen sausage pizza toppings during her last monthly kitchen round. The RD stated all expired items were expected to be removed during monthly rounds. The RD stated all food items were reviewed during monthly kitchen rounds to ensure all food items were labeled with receive date, open date, and use by dates. The RD stated she expected all staff to remove expired food items when expired and label all food items with a receive date, open date, and use by date, per facility policy and professional standards. The RD stated residents were at risk for foodborne illness if they ate spoiled honey mustard packets or frozen sausage pizza toppings. During an interview on 3/6/25 at 8:48 a.m. with the CDM, the CDM stated when hired all kitchen staff were trained to label and date food items with the receive date, open date, and use by date. The CDM stated when hired all kitchen staff were trained to discard expired food items. The CDM stated on 1/7/25 she provided an in-service to all kitchen staff for labeling food items with receive date, open date, and use by dates. During an interview on 3/6/25 at 8:53 a.m. with the Administrator (ADM), the ADM stated she oversaw the CDM and RD. The ADM stated she did not complete any observations with the CDM and RD during kitchen rounds. The ADM stated the CDM and RD used the Department of Health and Human Services Centers For Medicare and Medicaid Services, Kitchen/Food Service Observation form to complete monthly kitchen rounds together. The ADM stated the most recent kitchen audit completed by the CDM and RD was approximately two weeks ago but could not state the exact date. The ADM stated she was responsible to review the kitchen audit form after it was completed. The ADM stated she expected all kitchen staff to remove expired food items, per facility policy and training. The ADM stated she expected all kitchen staff to label and date food items with the receive date, open date, and use by date, per facility policy and training. During a review of the facility's most recent kitchen audit form titled, Department of Health and Human Services Centers For Medicare and Medicaid Services, Kitchen/Food Service Observation, undated, the form indicated the entire kitchen was assessed. The form indicated, a check mark was placed next to the observation, .Food products are discarded on or before the expiration date .food stored, prepared, distributed, and served in accordance with professional standards for food safety . indicating food storage was reviewed and assessed for expired food items. 3. During a concurrent observation and interview on 3/4/25 at 9:32 a.m. with the CDM and Dietary Aide (DA) 1 in the kitchen, a cell phone was observed on the kitchen spice preparation rack. The CDM and DA 1 verified the cell phone on the kitchen spice preparation rack. DA 1 stated the cell phone was hers and should not be placed on the kitchen spice preparation rack. The CDM stated no personal belongings were allowed in the kitchen. The CDM stated all personal belongings were expected to be kept in employee lockers or on the designated rack outside of the kitchen. The CDM stated personal items in the kitchen presented an infection control issue and could cause food borne illness. During an interview on 3/5/25 at 2:36 p.m. with the RD, the RD stated she expected all kitchen staff to maintain a safe, clean and sanitary kitchen environment. The RD stated she expected all staff to follow facility infection control policies. The RD stated a cell phone on the kitchen spice preparation rack did not maintain a safe, clean and sanitary kitchen environment or follow facility infection control policies. The RD stated it was a risk for cross contamination and food borne illness to have a cell phone on the kitchen spice preparation rack. During an interview on 3/6/25 at 8:48 a.m. with the CDM, the CDM stated when hired all kitchen staff were trained to keep personal items out of the kitchen. The CDM stated she expected all kitchen staff to follow orientation training. The CDM stated on 7/24/24 she provided an in-service to all kitchen staff regarding cell phone storage outside the kitchen and allowed only on breaks. During an interview on 3/6/25 at 8:53 a.m. with the ADM, the ADM stated she expected all kitchen staff to keep personal belongings out of the kitchen. The ADM stated no personal belongings should be placed on the kitchen spice preparation rack. The ADM stated it was unsanitary to have a cell phone on the kitchen spice preparation rack and could contaminate food and lead to food borne illness. During an interview on 3/7/25 at 5:34 p.m. with the Director of Nursing (DON), the DON stated he expected all kitchen staff to follow facility policies which included, infection control, hygiene and food safety. The DON stated he expected all kitchen staff to follow infection control, hygiene and food safety trainings and in-services. The DON stated he expected all food items to be labeled with a receive date, open date and use by date to ensure no food items were served expired. The DON stated all residents who ate at the facility were at risk for receiving an expired food item if left in the kitchen. The DON stated expired food items could cause gastrointestinal (stomach) upset or foodborne illness and make residents sick. 4. During a concurrent observation and interview on 3/4/25 at 2:24 p.m. with the CDM and Maintenance Supervisor (MS) in the employee breakroom, black dots substance was seen on the water pump in the ice machine. The CDM and MS verified the black dots on the water pump in the ice machine. The MS removed the black dots substance on the water pump with a white napkin. The CDM and MS verified the black substance on the white napkin. The CDM stated she expected the ice machine to be clean, sanitary and free from black substance. During a concurrent observation and interview on 3/5/25 at 2:36 p.m. with the RD, a picture of the ice machine, dated 3/4/25, was reviewed. The RD stated she observed black substance as black dots on the water pump. The RD stated she expected the ice machine to be free from black substance. The RD stated the black substance on the water pump contaminated the ice and was a risk for foodborne illness to all 44 residents who ate at the facility. During an interview on 3/6/25 at 8:53 a.m. with the ADM, the ADM stated she expected the ice machine to always be free from black substance and clean. During a concurrent observation and interview on 3/7/25 at 5:34 p.m. with the DON, a picture of the ice machine, dated 3/4/25, was reviewed. The DON stated he observed black substance as black dots on the water pump. The DON stated he expected the ice machine to be clean and free from black substance. During a review of the facility's job description document titled, Dietary Aide, dated 2023, the document indicated, . follows appropriate safety and hygiene measures at all times to protect residents .follows established infection control policies and procedures .as a condition of employment, completes all assigned training and skills competency .maintains food storage areas in a clean and properly arranged manner at all times .assists in inventory and storing in-coming food, supplies, etc., as necessary . During a review of the facility's job description document titled, Dietary Manager, dated 2023, the document indicated, .oversees the budget and purchasing of food and supplies, and food preparation, services, and storage .maintains a clean and sanitary environment .prepares cleaning schedules and maintain equipment to ensure food safety .ensures proper sanitation and safety practices of staff .establishes a culture of compliance by adhering to all facility policies and procedures .follows appropriate safety and hygiene measures at all times to protect residents .follows established infection control policies and procedures . During a review of the facility's job description document titled, Dietician, dated 2023, the document indicated, .performs regular inspections of food service areas for sanitation, order, safety, and proper performance of assigned duties .follows established infection control policies and procedures . During a review of the facility's job description document titled, Maintenance Director, dated 2023, the document indicated, .follows appropriate safety and hygiene measures at all times to protect residents .follows established infection control policies and procedures . During a review of the facility's job description document titled, Administrator, dated 2023, the document indicated, . conducts periodic observations of in-service education to ensure staff members delivering the education are competent with the knowledge and skill set required to accomplish employee learning . During a review of the facility's competency checklist document titled, Dietary Manager Competency, dated 2/19/24, the document indicated, the CDM received initial training on, .infection control .food storage .meal preparation .tray line/diet card . and demonstrated competency. During a review of the facility's competency checklist document titled, Food & Nutrition: Competency Checklist-Food Service Worker, dated 2/10/25, the document indicated, DA 1 received initial training on, .infection control practices . sources of food borne illness .correctly label and date foods . and demonstrated competency. During a review of the facility's in-service record document titled, Label/date, Puree Technique, [NAME] Temp vs Holding Temp, Temp Danger Zone, dated 1/7/25, the document indicated, the document indicated, .All foods must have a label w/ [with] what it is .R: receive date .O: open date .UB: use by date . During a review of the facility's in-service record document titled, Cell Phones, Ear Pods, Breaks, Rest of the time is company time, need to clean or organize or re-stock, dated 7/24/24, the document indicated, cell phones were only allowed on breaks. During a review of the facility's policy and procedure (P&P) titled, Store/Prepare/Serve Guidelines, dated 10/2022, the P&P indicated, .Food should be provided in a form .that meets each resident's individual needs in accordance with his or her assessment and care plan . During a review of the facility's P&P titled, Food Safety Requirements, dated 11/2022, the P&P indicated, .Food will also be stored, prepared, distributed and served in accordance with professional standards for food service safety . food safety practices shall be followed throughout the facility's entire food handling process .storage of food in a manner that helps prevent deterioration or contamination of the food, including from growth of microorganisms .equipment used in the handling of food .and other equipment that comes in contact with food .staff shall adhere to safe hygienic practices to prevent contamination of foods from hands or physical objects .additional strategies to prevent foodborne illness include .cleaning and sanitizing the internal competent of the ice machine . During a review of the facility's P&P titled, Ice Machines and Portable Ice Carts, dated 11/2024, the P&P indicated, .it is the policy of this facility to ensure that ice machines/carts are .cleaned, and maintained as per Federal, State, and local, or facility guidance .and current standards of practice . ice machines/carts can be prone to microbial contamination due to .poor cleaning or maintenance of equipment .proper cleaning, maintenance, and infection control in relation to ice machines is important to decrease the risk of illness to residents, staff and visitors .The maintenance director or other designee is responsible for cleaning and maintain the ice machine at the facility . The ice machine(s) or carts will be cleaned at any time contamination may have occurred or when visibly soiled . During a review of the facility's P&P titled, Infection Prevention and Control Program, dated 11/2024, the P&P indicated, .this facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary and comfortable environment .all staff are responsible for following all policies and procedures related to the program .standard precautions .environmental cleaning and disinfection shall be performed according to facility policy .all staff have responsibilities related to the cleanliness of the facility .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to provide a safe, functional, comfortable and homelike environment for residents, staff and the public when: 1. Five of six resident rooms did not have a properly functioning screen doors and one screen door was missing. 2. Three of sixteen resident doors were not functioning properly. These failures had the potential of violating residents' rights to their privacy and at risk of accidents which could lead to serious health condition. Findings: 1. During initial tour a concurrent observation and interview on 3/4/25 at 10:38 a.m. with Resident 42 in his room, Resident 42 was sitting at the edge of his bed. Resident was appropriately dressed and answered questions. Resident 42 stated he had problem with his screen door not working and door to his room was heavy and difficult to closed. Resident 42 stated he reported the concerns to the facility and have not fixed the problem. During a review of Resident 42's admission Record, dated 3/6/25, the AR indicated Resident 42 was admitted to the facility om 2/6/25 with diagnoses which included muscle weakness and multiple fractures (break in the bones). During a review of Resident 42's Minimum Data Set (MDS-a federally mandated resident assessment tool) assessment dated [DATE], indicated Resident 42's Brief Interview for Mental Status (BIMS-screening tool used in nursing home to assess cognition) assessment score was 15 out of 15 (0-15 scale [0-6 severe cognitive deficit, 7-12 moderate cognitive deficit, 13-15 no cognitive deficit]) indicating Resident 42 had no cognitive impairment. During an interview on 3/6/25 at 3:40 p.m. with Certified Nurse Aide (CNA) 5, CNA 5 stated she was not aware the screen doors for Rooms' 15, 16, 17, 1, 2, and 3 were not working properly. CNA 5 stated she did not remember resident, or staff complained about the screen doors not working properly. CNA 5 stated when there was building issues needing to be fixed, she reports to the Maintenance Supervisor (MS) in person or enter into their electronic reporting called TELS (Team Electronic Library System- electronic building management). 2. During a concurrent observation and interview on 3/4/25 at 10:40 a.m. with Resident 40, Resident 40 complained about his door being heavy and difficult to open and closed. Resident stated he reported it but no one had tried to fix it. Resident 40 stated it was difficult for him to open and closed his door. During an interview on 3/6/25 at 3:46 p.m. with CNA 6, CNA 6 stated she was not aware of rooms' 15, 1 and 6's door not working properly. CNA 6 stated she did not remember residents or staff complained about rooms' 1, 6 and 15's doors not closing or opening properly. CNA 6 stated she reports building issues to MS in person. CNA 6 stated there was no binder to write building issues needed to be fixed. During a concurrent observation and interview on 3/5/5 at 2:35 p.m. with Maintenance Supervisor (MS), MS walked outside through the sliding door of Resident 40 and checked screen door of Resident 40. The MS stated Resident 40's screen door was not working properly. The MS checked the additional screen doors for Rooms' 16, 17, 1, 2, and 3. The MS stated the screen door for rooms' 16, 17, 1, and 2 were not working properly and room [ROOM NUMBER] did not have a screen door. The MS stated he was not aware room [ROOM NUMBER]'s door was difficult to open and close. The MS stated he was aware of Rooms' 1 and 6's doors were difficult to close and open when the new floors were installed and was in the process of fixing the doors. The MS stated the doors and screen doors should have been working properly because of safety issues which could result in serious health condition. The MS stated he made rounds of the facility at least once a week to ensure facility was safe and doors working properly but did not notice the screen doors were not working properly. During an interview on 3/7/25 at 2:05 p.m. with LVN 3, LVN 3 stated she did not remember any staff or resident complained about screen doors not working properly and missing screen door. LVN 3 stated she was not aware of Rooms' 1, 6 and 15 doors not working properly. LVN 3 stated she reports building issues in person to MS or use TELS system to report issues. During an interview on 3/7/25 at 6:22 p.m. with the Administrator (ADM), the ADM stated her expectation for the MS was to maintain the building. The ADM stated she was not aware the doors and screen doors were not closing or opening properly. ADM stated, All sliding doors should be working properly to keep it as homelike as possible. The ADM stated she was not aware of Rooms' 1, 6 and 15 doors not working properly. The ADM stated it was important to maintain doors in good working condition for safety issue. During a review of facility's policy and procedure (P&P) titled, Safe and Homelike Environment, dated 2024, the P&P indicated, .The facility will provide a safe, clean, comfortable and homelike environment . the physical layout of the facility maximizes resident independence and does not pose a safety risk . Report any furniture in disrepair to Maintenance promptly. Report any unresolved environmental concerns to the Administrator . During a review of the facility's document titled, Maintenance Director, Job Description, dated 2023, the document indicated, . Plans, develops, organizes, implements . Ensures facility remains in compliance with all federal, state and local regulations for Life and Safety Code compliance . Ensures proper planning, direction, participation, and supervision of both preventative and unplanned maintenance and repair activities in the facility, which includes painting, plumbing, carpentry . Develops and implements preventative maintenance tasks, document instructions an procedures for the preventative maintenance of facility .

Based on observation, interview, and record review, the facility failed to ensure residents received adequate supervision to prevent elopement for one of three sampled residents (Resident 1) who was a high risk for elopement (when a resident, who is incapable of adequately protecting themselves, departs the facility unsupervised and undetected) when Resident 1 eloped from the facility on 11/6/24. This failure placed Resident 1 ' s safety at risk when Resident 1 was found on the side of the road a mile and a half away from the facility by staff. Findings: During record review of Resident 1 ' s admission Record (AR- a document that provides resident contact details, a brief medical history), the AR indicated, Resident 1 had diagnoses which included .TRAUMATIC BRAIN INJURY (alteration in brain function caused by an external force such as a blow, bump or jolt to the head) .ALCOHOL DEPENDENCE .SEIZURES (a sudden uncontrolled burst of electrical activity in the brain) .HISTORY OF FALLING .ANXIETY DISORDER (mental health condition that causes excessive and persistent feelings of worry and uneasiness) .MAJOR DEPRESSIVE DISORDER (a mood disorder that causes a persistent feeling of sadness and loss of interest) .PSYCHOSIS (a collection of symptoms that affect the mind where an individual loses touch with reality) .DIFFICULTY IN WALKING . During a review of Resident 1's Minimum Data Set (MDS- a standardized assessment and care screening tool), dated 8/8/24, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS- an evaluation of attention, orientation and memory recall) indicated a score of 9 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment), indicating Resident 1 had moderate cognitive impairment. During an observation on 11/13/24 at 9:20 a.m. outside on facility premises, there was a metal fence surrounding the facility premises that was 8 feet tall. A locked gate was located by the parking lot for visitors and employees to enter and exit the enclosed premises. The locked gate was opened with a key by a staff member. During an interview on 11/13/24 at 9:29 a.m. with Director of Nursing (DON), the DON stated, a hospitality aide (HA) was assigned every shift to do outdoor perimeter checks around the facility premises every 15 minutes. The DON stated, HA had started the shift on 11/6/24 and at 6:41 a.m. had found a meal cart placed next to the fence behind a shed. The DON stated, the HA used a walkie-talkie (a small portable radio used for receiving and sending a message) to alert staff inside the facility to perform a head count in order to identify any potentially missing residents. The DON stated, Resident 1 was identified to be missing. The DON stated, a staff member was driving to work, spotted Resident 1 on the side of the road and called the facility to alert staff of his location. The DON stated, Resident 1 was brought back to the facility by Director of Staff Development (DSD) and Licensed Vocational Nurse (LVN) 2. The DON stated, she believed Resident 1 had used the kitchen cart to climb over the facility ' s fence. The DON stated, Resident 1 had eloped before by putting a barrel on his wheelchair and climbing over the facility ' s fence. The DON stated, the perimeter checks every 15 minutes was implemented after Resident 1 ' s first elopement. The DON stated, the HA assigned to monitor the perimeter during Resident 1 ' s elopement was inside. The DON stated, the HA should should have been outside the facility building to monitor the facility perimeter. During an interview on 11/13/24 at 9:50 a.m. with HA 1, HA 1 stated, on 11/6/24 at 6:41 a.m. she was assigned to monitor the facility outside perimeter, grabbed a walkie talkie and began the first perimeter check of her shift. HA 1 stated, she saw a kitchen meal cart with a temporary orange fence wrapped around the cart. HA 1 stated, the perimeter checks should have been performed every 15 minutes. HA 1 stated, the prior HA should have been outside looking for suspicious items or equipment residents could use to elope and climb over the fence or cause harm. HA 1 stated, the prior HA should have been outside at all times except on a restroom break or lunch break. HA 1 stated, it was important to perform the perimeter checks accurately and to provide resident supervision to ensure the safety of residents, especially residents who are high elopement risk. During a concurrent observation and interview on 11/13/24 at 10:00 a.m. with Resident 1 in the dining room, Resident 1 was observed talking and interacting with staff. Resident 1 stated, he left the facility premises over a fence to walk home. During an interview on 11/13/24 at 10:17 a.m. with LVN 1, LVN 1 stated, Resident 1 was an elopement risk. LVN 1 stated, Resident 1 was at danger of falling, getting hit by a car or receiving skin injuries when he eloped due to the lack of supervision he received. During an interview on 11/13/24 at 10:30 a.m. with DSD, DSD stated, Resident 1 was a high elopement risk. DSD stated, staff were educated to remove all barrels and other objects outdoors as well as lock gates for resident safety. DSD stated, the HA was told to do perimeter checks, ensure gates were locked and identify suspicious activity amongst residents. DSD stated, HAs' were instructed to remain outdoors at all times except for bathroom breaks or lunch breaks. DSD stated, HA's were told to use the walkie talkie to notify staff inside of any irregularities identified outside or if another staff member was needed to relieve them of their duties for a break. DSD stated, it was important to provide adequate supervision to residents and perform perimeter checks accurately to prevent residents from eloping. DSD stated, on 11/6/24 at around 6:41 a.m. HA 1 saw a kitchen meal cart next to the fence and notified staff to perform a count of all residents and a code green (indicating a missing resident) was initiated to search for Resident 1 at 6:50 a.m. DSD stated, staff searched the facility premises and the surrounding streets for Resident 1. DSD stated, Resident 1 was found on the corner of a street one and a half miles away from the facility at 7:02 a.m. DSD stated, Resident 1 was brought back to the facility at 7:15 a.m. and assessed for injuries. DSD stated, Resident 1 had eloped prior to this incident. During an interview on 11/13/24 at 11:52 a.m. with the DON, the DON stated, HA 2 assigned to monitor the facility perimeter was indoors at the time of Resident 1 ' s elopement. The DON stated, the training and expectation for HA 2 was to stay outside, do shift report (communication between staff when responsibility and accountability is transferred) outside, do perimeter checks every 15 minutes, ensure gates are closed and locked, observe for suspicious activity and notify staff indoors of any abnormal findings. The DON stated, the facility should have ensured resident ' s environment was free from accident hazards and each resident received adequate supervision to prevent elopement and accidents. The DON stated, there was a failure with staff to provide resident supervision because HA 2 did not perform the perimeter checks every 15 minutes. DON stated, the failure to provide adequate supervision impacted Resident 1 ' s safety and Resident 1 could have been injured during his elopement. During a telephone interview on 11/13/24 at 5:09 p.m. with LVN 2, LVN 2 stated, Resident 1 was identified missing by staff when a perimeter check revealed a kitchen meal cart found outside next to the fence. LVN 2 stated, an employee found Resident 1 walking on the side of the road about a mile and a half away. LVN 2 stated, DSD and LVN 2 drove to find Resident 1. LVN 2 stated, she last saw Resident 1 during medication pass about an hour before the elopement. LVN 2 stated, Resident 1 was taken back to the facility after initially resisting. LVN 2 stated, the perimeter checks was implemented due to multiple past resident elopements. LVN 2 stated, the residents are under the care of the facility and adequate supervision should have been provided. LVN 2 stated, Resident 1 could have been hit by a truck and seriously injured when he eloped. During a review of Resident 1 ' s IDT [Interdisciplinary Care Team]- Interdisciplinary Post Event Note (IPEN), dated 9/3/24, the IPEN indicated, .IDT met to review elopement occurred on 9/2/24 where Resident was last seen on 0945 [9:45 a.m.] headed towards room by on duty staff. At 1015 [10:15 a.m.] .on duty nurse received a call asking if we had a resident under the name of [Resident 1] at our building. Head count was done by staff. Resident was noted to be missing. Near the back gate, resident wheelchair was found with a barrel on top .at 1020 staff went to pick up resident. Person who picked up resident stated resident was noted to be waving cars down .Full body check was done. Minor scratches were noted to knees upon assessment .he was able to describe to the IDT that he went in the back of the facility and used w/c [wheelchair] to climb over the wood fence and went on top of the barrel and then went over the fence .He stated, ' I was just going home as my home is nearby ' . During a review of Resident 1 ' s Change in Condition Evaluation (CIC), dated 11/6/24, the CIC indicated, .Elopement .This started on .11/06/2024 .Resident noted missing from facility. Found walking at intersection of [cross streets] . Resident returned to facility at 0715 [7:15 a.m.] .Resident agitated and verbally aggressive with staff. Resident says sister told him to walk to his house . During a review of Resident 1 ' s IPEN, dated 11/6/24, the IPEN indicated, .The Interdisciplinary Team (IDT) met with the resident following an elopement attempt earlier this morning. The resident, who is ambulatory without assistance .stated his intention to ' go home ' .resident responded that he intended to walk as his sister told him to walk home .Staff observed a rack positioned against the fence, which the resident confirmed he used to climb over .Date and Time of Event .11/06/2024 06:45 [6:45 a.m.] . During a review of Perimeter Rounds: Check List (PRCL), dated 11/6/24, the PRCL indicated, Ensure no barrels are present .Ensure gates are closed at all times .Ensure no equipment are present for resident ' s safety . During a review of the facility ' s policy and procedure (P&P) titled, Elopements and Wandering Residents, dated 11/24, the P&P indicated, .This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk . ' Elopement ' occurs when a resident leaves the premises or a safe area without authorization .and/or necessary supervision to do so .The facility is equipped with door locks/alarms to help avoid elopements .Alarms are not a replacement for necessary supervision .Adequate supervision will be provided to help prevent accidents or elopements .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide adequate supervision for one of one sampled resident (Resident 1) who was a high risk for elopement when Resident 1 eloped from the facility on 9/2/24. This Failure placed Resident 1's safety at risk when Resident 1 was found on the side of the road half a mile away from the facility by a passing motorist. Findings: During an observation on 9/18/24, at 8:20 a.m., the facility building was surrounded with an 8-foot-tall metal fence. The fence extended entirely around the building and staff & visitors entered and exited the facility through a single locked gate which opened with a key. During a concurrent observation and interview on 9/18/24, at 8:40 a.m., with Sitter 1, in Resident 1's room, Sitter 1 was sitting at Resident 1's bedside. Sitter 1 stated she was assigned to provide one-on-one monitoring and supervision for Resident 1. Sitter 1 stated Resident 1 recently eloped. During a review Resident 1's Progress Notes (PN) dated 9/2/24, the PN indicated, Resident was last seen at 0945 headed towards room. At 1015 call was received asking if we had a resident under the name of [Resident 1] at our building . Resident was noted to be missing. Near the back gate, resident wheelchair was found with a barrel on top. Person [passing motorist] on the phone stated he was at [name of street]. At 1020 staff [facility staff] went to pick up resident. Person [passing motorist] who picked up resident stated resident was noted to be waving cars down on [name of cross streets] .Resident was brought back to facility by staff . Minor scratches were noted to knees . During a review of Resident 1's admission Record (AR- a document that contains patient's medical and demographic information) dated 9/18/24, the AR indicated Resident 1 was a [AGE] year old male admitted to the facility on [DATE] with diagnoses which included traumatic brain injury (TBI- caused by a forceful bump, blow, or jolt to the head, or from an object entering the brain, can cause temporary or short-term problems with brain function, including problems with how a person thinks, understands, moves, communicates, and acts, possibly leading to severe and permanent disability, and even death), psychosis (refers to a collection of symptoms that affect the mind, where there has been some loss of contact with reality, a person ' s thoughts and perceptions are disrupted and they may have difficulty recognizing what is real and what is not), history of falling, difficulty walking, alcohol dependence (a chronic disease in which a person craves drinks that contains alcohol) and seizure (a sudden uncontrolled burst of electrical brain activity in the brain). During a review of Residents 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 of Mental status assessment (BIMS - assessment of cognitive status for memory and judgement) scored 9 of 15 (a score of 13-15 indicates cognitively intact, 8-12 indicates moderately impaired, and 0-7 indicates severe impairment). The BIMS assessment indicated Resident 1 was moderately impaired. During an interview on 9/18/24 at 8:55 a.m. with the Maintenance Supervisor (MS), the MS stated Resident 1 eloped from the rear corner of the facility. The MS stated Resident 1 placed a barrel on top of the wheelchair and climb over the 8-foot fence and slid down to the other side of the fence. The MS stated the barrel should have not been left near the fence. During a concurrent interview and record review on 9/18/24 at 9 a.m. with the Administrator the facility document titled Event 5-Day Follow Up (5-Day), dated 9/6/24 was reviewed., The 5-Day indicated, On 9/2/2024 at 10:15 A.M. Staff member received a call to facility asking if we had a resident under the name of [Resident 1] at our building. Head count was done by staff. Resident was noted to be missing. [Resident 1] was last seen at 0945 [a.m.] headed toward room. Near the back gate, resident wheelchair was found with a barrel on top. Person on phone stated he was at [an address about 2.3 miles from facility] at the corner market. At 1020 [a.m.] staff sent to pick up resident. Person who picked up resident stated resident was noted to be waving cars down [at an address about ½ mile from facility]. He then picked him up and drove [Resident 1] to [local police department], however it was closed and drove to corner market. Resident was brought back to facility by staff member, Resident was able to walk and get into car with no issues noted. Full body check was done. Minor scratches were noted to knees. Resident denies falling or hitting head during event Near the back gate, resident wheelchair was found with a barrel on top. All gates securely locked. Resident stated he was attempting to go home. The Administrator stated the facility was known in the community and acute care hospitals as a secured and locked facility, and we admitted a lot of elopement risk residents from other facilities. The Administrator stated Resident 1 showed the area where he eloped and used the barrel to climb over the fence. The Administrator stated the barrel should have not been stored near the fence. During an interview on 9/18/24 at 9:30 a.m. with License Vocational Nurse (LVN) 1, LVN 1 stated she was the nurse on duty when Resident 1 eloped. LVN 1 stated on 9/2/24 she received a call asking if we have resident named [Resident 1]. LVN 1 stated she went outside and at the back corner of the facility saw a barrel stacked on top of Resident 1's wheelchair. LVN 1 stated Resident 1 used the barrel to climb over the fence and eloped from the facility. LVN 1 stated Resident 1 was picked up by a passing motorist half a mile from the facility and was taken to the police station. LVN 1 stated the police station was closed because of the holiday and the motorist drove to a store and called the facility. During an interview on 9/18/24, at 10:55 a.m., with the Administrator, the Administrator stated the facility had four doors which lead to the outside of the building. The main door and one other door does not have a door alarm, and the other two doors had a door alarm. The Administrator stated the outside area of the building was surrounded with eight-foot-tall fence and was used by residents to get fresh air. The Administrator stated, I don't know exactly how many residents go outside, a good chunk of them do . The Administrator stated the facility staff does not provide resident supervision once outside the building within the fenced area. During a review of the facility Policy and Procedure (P&P) titled, Elopements and Wandering Residents, dated 10/24, the P&P indicated, in part, Policy: This facility ensures that residents who exhibit wandering behavior and/or are risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. Elopement occurs when a resident leaves the premises or a safe area without authorization. and/or any necessary supervision to do so. Policy Explanation and Compliance Guidelines: The facility is equipped with door locks/alarms to help avoid elopements. Adequate supervision will be provided to help prevent accidents or elopements.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide adequate supervision for one of one sampled resident (Resident 1) who was a high risk for elopement when Resident 1 eloped from the facility on 6/16/24. This Failure placed Resident 1's safety at risk when Resident 1 was found walking on the side of the road ½ a mile away from the facility. Findings: During a review of Resident 1's admission Record (AR- a document containing resident profile information) dated 6/27/24, the AR indicated Resident 1 was a [AGE] year-old male admitted to the facility with diagnoses included traumatic brain injury (TBI, serious injury to the brain that affects problems with how a person thinks, understands, moves, communicates, and acts), and mild cognitive impairment (impaired ability to remember, think, or make decisions). During a review of Resident 1's Care Plan (CP), dated 6/26/24, the CP indicated Resident 1 is an elopement risk/wanderer related to impaired safety awareness, Resident wanders aimlessly. The resident's safety will be maintained. The resident will not leave facility unattended. The CP dated 3/5/24 indicated Resident 1 has impaired cognitive function or impaired thought processes related to head injury (TBI). During a review of Resident 1's Minimum Data Set (MDS, a comprehensive, standardized assessment), dated 5/15/24, the MDS indicated at Question C500 Brief Interview for Mental Status, a score of 8 out of a possible 15, which indicated moderately impaired cognition. During a review of Resident 1's Progress Notes (PN), dated 6/17/24, the PN indicated, on 6/16/24, Resident 1 was noted walking down the street. CNA [Certified Nursing Assistant] staff brought resident back to the facility. Upon arrival at 11:44 a.m., Resident was unable to state how or when he left facility. Resident last seen approx [approximately]. 10:30 a.m. by staff member during smoke break. During an interview with the Administrator, on 6/27/24, at 12 p.m., the Administrator stated Resident 1 was not on one-to-one monitoring at the time of his elopement on 6/16/24. The Administrator stated Resident 1 had been on one-to-one monitoring due to past elopement, but the monitoring was discontinued due to no elopement attempts. The Administrator stated she had seen Resident 1 with paper clips and twigs from the tree unsuccessfully trying to pick the gate lock. The DON stated Resident 1 sits near the gate and tried to take every opportunity to leave the facility through the gate when staff enters and leaves the facility, and we constantly redirect him. During an interview on 6/27/24, at 2:55 p.m., with CNA 1, CNA 1 stated she was the one who found Resident 1 walking on the side of the road on 6/16/24 at around 11:30 a.m. CNA 1 stated it was her day off from work and was driving doing some errands and saw a person walking on the opposite side of the road. CNA 1 stated she slowed down and noticed it was Resident 1. CNA 1 stated she pulled over and did a U-turn to be on the same side of the road with Resident 1. CNA 1 stated she got out of the car and talked to Resident 1. CNA 1 stated Resident 1 recognized her. CNA 1 stated Resident 1 was wearing a t-shirt, sweatpants, hat, and shoes. CNA 1 stated Resident 1 was sweaty and did not have water. CNA 1 stated she told Resident 1 to get inside the car and she will take him home. CNA 1 stated she called and notified the facility she found Resident 1 walking on the side of the road. CNA 1 stated the facility did not know Resident 1 eloped. CNA 1 stated she brought Resident 1 back to the facility. During a concurrent observation and interview on 6/27/24, at 3:15 p.m., with the Maintenance Supervisor (MS), the facility's front gate was observed. The MS stated this was the only area where staff, residents and visitors enter and leave the facility. The entire facility is surrounded by an 8-foot-tall metal fence. The gate was observed opening and closing several times at varying degrees, the gate closed promptly and securely each time. The gate and fence were made of robust steel, the gate closed forcefully with a loud 'clang' each time. The MS stated he checked the gate weekly and had made no repairs since the gate was operating normally. The MS stated he sees no evidence the gate lock had been tampered, has never found debris in the keyhole, no scratches other than the normal wear, no debris on ground at gate, and no evidence the lock had been picked. The MS stated there were no footholds or other methods to climb over the gate or fence. Three staff observed leaving the facility, gate lock opened with a key, and the gate promptly closed shut at each exit. During an interview on 7/1/24, at 11:05 a.m., with the Activity Director (AD), the AD stated she recalled seeing Resident 1 on the day of his elopement on 6/16/24, between 10:20 a.m. and 10:30 a.m. The AD stated she was taking her morning break and saw Resident 1 sitting in a chair by the front gate. The AD stated during this time, a Dietary Aide (DA 1) had opened the gate to take some garbage out, and she assisted DA 1 with the gate, and ensured the gate was closed. The AD stated, I honestly don't know how he [Resident 1] got out. The AD stated when her break was over, the gate was closed, and Resident 1 was still sitting by the gate with no staff present. The AD stated she knew a second Dietary Aide reported to work and entered the facility a few minutes later, after she and DA 1 had returned inside the facility. During an interview on 7/1/24, at 11:12 a.m., with DA 1, she stated she was working in the kitchen on 6/16/24 and had to take out the trash. DA 1 stated the AD had assisted her with the gate and recalled seeing Resident 1 sitting by the gate. DA 1 stated, I always make sure the gate is shut, I'm really paranoid about that. I always pull on it to make sure it is shut, but it always shuts on its own. Even if you wanted to leave it open a little bit, it closes on its own. I know that a few minutes later, a little before 11 a.m., [DA 2] came into work through that gate. During an interview on 7/1/24, at 4:25 p.m., with DA 2, DA 2 stated he reported to work and entered the gate on 6/16/24 at 10:58 a.m. DA 2 stated he used his key to open the gate and heard the gate closed. DA 2 stated he did not see Resident 1 anywhere near the gate. During a review of the facility Policy and Procedure (P&P) titled, Elopements and Wandering Residents, dated 10/24, the P&P indicated, in part, Policy: This facility ensures that residents who exhibit wandering behavior and/or are risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. Elopement occurs when a resident leaves the premises or a safe area without authorization. and/or any necessary supervision to do so. Policy Explanation and Compliance Guidelines: The facility is equipped with door locks/alarms to help avoid elopements. Adequate supervision will be provided to help prevent accidents or elopements.

Based on observation, interview and record review, the facility failed to provide adequate supervision for one of two sampled residents (Resident 1) who was a high risk for elopement when Resident 1 eloped from the facility on 5/15/24 at 7:40 PM and was found by the Sheriff's Department on 5/16/24 at 4 AM in the orchard a mile away from the facility. This failure resulted in Resident 1 leaving the facility without supervision for over eight hours which had the potential to cause injuries. Findings: During an observation on 7/7/24 at 2:35 PM Resident 1 was sitting in the lobby smiling and waving hello to visitors. Resident 1 had an approximately 1-millimeter dot size scabbed on the forehead and on the forearm. During a review of Resident 1's admission Record (AR-contains important information about a patient such as their personal details, the reason for admission and medical history), dated 6/10/24, the AR indicated Resident 1 was admitted to the facility with diagnoses that included traumatic brain injury (TBI, serious injury to the brain that affects problems with how a person thinks, understands, moves, communicates, and acts), and dementia (impaired ability to remember, think, or make decisions). During a review of Resident 1's Care Plan (CP), dated 2/23/24, the CP indicated Resident 1 is an elopement risk/wanderer related to impaired safety awareness, Resident wanders aimlessly. The resident's safety will be maintained. The resident will not leave facility unattended. The CP dated 3/5/24 indicated Resident 1 has impaired cognitive function or impaired thought processes related to head injury (TBI). During a review of Resident 1's Progress Notes (PN), dated 5/15/24, at 11:10 PM, the PN indicated Resident 1 .had not been seen in facility. All staff was searching the entire facility, rooms, restrooms, outside perimeter, parking lot, and nearby streets. Resident was unable to be located . [local police department] were notified. During a review of the facility document titled Event 5-Day Follow Up (FU), dated 5/20/24, the FU indicated, On 5/15/24, at 7:40 PM PST [Pacific Standard Time] staff notified charge nurse that resident had not been seen in facility. Facility staff started searching entire facility, rooms, restrooms, outside perimeter, parking lot and nearby streets. Resident was unable to be located. [Local law enforcement and many others] went on search for missing resident. Resident was found by [local law enforcement] unit at 4 AM PST on 5/16/24. Resident was found hiding in fields about 1 mile from facility. Around the time resident is estimated to leave the facility [a] family of another resident was leaving the facility. Resident may have slipped out with the group. During an observation of the facility on 6/7/24, at 1:59 PM, an approximately 7-foot-tall metal fence was noted in front of the facility. The entry from the parking area was locked gate with signs indicating FOR OUR RESIDENT'S SAFETY ALWAYS CLOSE AND LOCK THIS GATE and PLEASE SHUT GATE visible from the entry (parking lot) side. A doorbell was present, and once rung, a staff person came and opened gate with a metal key inserted into the gate's doorknob. During a concurrent observation and interview on 6/7/24, at 2:11 PM, with the Infection Preventionist (IP), the entire perimeter of the facility was observed. The 7-foot-tall metal fence was noted surrounding the entire facility. The IP stated there were a total of four gates to the facility, but the staff and visitors enter and leave the facility through the main gate, which was always kept locked with a key. The other three gates were noted to be tightly closed with a padlock and/or chain. There were no visible means for a resident to climb over, or through, the fence. The same signs were noted at the exit (facility side) side of main gate indicating, FOR OUR RESIDENT'S SAFETY ALWAYS CLOSE AND LOCK THIS GATE and PLEASE SHUT GATE. The IP verified the findings and stated, There's no way [Resident 1] could have gotten over this fence. During an interview with the Director of Nursing (DON), on 6/7/24, at 2:40 PM, the DON stated, We are a locked facility. The fence surrounds the entire building, and the only way in or out is through the locked gate. The DON stated Resident 1 was ambulatory. The DON stated before the incident Resident 1 wanted to go to his daughter's house approximately 25 miles from the facility. The DON stated Resident 1 was observed standing near the entry gate watching visitors and staff in and out the facility. The DON stated only the facility staff had a key to the gate. The DON stated we searched for Resident 1 and looked for chairs, barrels against the fence, any methods for him to climb over the fence, and we did not find anything. The DON stated we determined Resident 1 was not in the facility and notified the Sheriff's department. The DON stated Resident 1 was found by Sheriff's department hiding in an orchard a mile from the facility. The DON stated Resident 1 had minor scratches and have healed in a week. The DON stated Resident 1 had cognitive issues and was not able to tell us how he got out. The DON stated we had some visitors leave the facility on 5/15/24 at about 7:40 PM he must have exited the facility when the visitors left. The DON stated facility staff had to be there to unlock the gate for the visitors to exit the facility. The DON stated more likely Resident 1 exited the facility with the visitors without facility staff noticing. During a review of the facility Policy and Procedure (P&P) titled, Elopements and Wandering Residents, dated 10/24, the P&P indicated, in part, Policy: This facility ensures that residents who exhibit wandering behavior and/or are risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. Elopement occurs when a resident leaves the premises or a safe area without authorization. and/or any necessary supervision to do so. Policy Explanation and Compliance Guidelines: The facility is equipped with door locks/alarms to help avoid elopements. Adequate supervision will be provided to help prevent accidents or elopements. Based on observation, interview and record review, the facility failed to provide adequate supervision for one of two sampled residents (Resident 1) who was a high risk for elopement when Resident 1 eloped from the facility on 5/15/24 at 7:40 PM and was found by the Sheriff's Department on 5/16/24 at 4 AM in the orchard a mile away from the facility. This failure resulted in Resident 1 leaving the facility without supervision for over eight hours which had the potential to cause injuries. Findings: During an observation on 7/7/24 at 2:35 PM Resident 1 was sitting in the lobby smiling and waving hello to visitors. Resident 1 had an approximately 1-millimeter dot size scabbed on the forehead and on the forearm. During a review of Resident 1's admission Record (AR-contains important information about a patient such as their personal details, the reason for admission and medical history), dated 6/10/24, the AR indicated Resident 1 was admitted to the facility with diagnoses that included traumatic brain injury (TBI, serious injury to the brain that affects problems with how a person thinks, understands, moves, communicates, and acts), and dementia (impaired ability to remember, think, or make decisions). During a review of Resident 1's Care Plan (CP), dated 2/23/24, the CP indicated Resident 1 is an elopement risk/wanderer related to impaired safety awareness, Resident wanders aimlessly. The resident's safety will be maintained. The resident will not leave facility unattended. The CP dated 3/5/24 indicated Resident 1 has impaired cognitive function or impaired thought processes related to head injury (TBI). During a review of Resident 1's Progress Notes (PN), dated 5/15/24, at 11:10 PM, the PN indicated Resident 1 .had not been seen in facility. All staff was searching the entire facility, rooms, restrooms, outside perimeter, parking lot, and nearby streets. Resident was unable to be located . [local police department] were notified. During a review of the facility document titled Event 5-Day Follow Up (FU), dated 5/20/24, the FU indicated, On 5/15/24, at 7:40 PM PST [Pacific Standard Time] staff notified charge nurse that resident had not been seen in facility. Facility staff started searching entire facility, rooms, restrooms, outside perimeter, parking lot and nearby streets. Resident was unable to be located. [Local law enforcement and many others] went on search for missing resident. Resident was found by [local law enforcement] unit at 4 AM PST on 5/16/24. Resident was found hiding in fields about 1 mile from facility. Around the time resident is estimated to leave the facility [a] family of another resident was leaving the facility. Resident may have slipped out with the group. During an observation of the facility on 6/7/24, at 1:59 PM, an approximately 7-foot-tall metal fence was noted in front of the facility. The entry from the parking area was locked gate with signs indicating FOR OUR RESIDENT'S SAFETY ALWAYS CLOSE AND LOCK THIS GATE and PLEASE SHUT GATE visible from the entry (parking lot) side. A doorbell was present, and once rung, a staff person came and opened gate with a metal key inserted into the gate's doorknob. During a concurrent observation and interview on 6/7/24, at 2:11 PM, with the Infection Preventionist (IP), the entire perimeter of the facility was observed. The 7-foot-tall metal fence was noted surrounding the entire facility. The IP stated there were a total of four gates to the facility, but the staff and visitors enter and leave the facility through the main gate, which was always kept locked with a key. The other three gates were noted to be tightly closed with a padlock and/or chain. There were no visible means for a resident to climb over, or through, the fence. The same signs were noted at the exit (facility side) side of main gate indicating, FOR OUR RESIDENT'S SAFETY ALWAYS CLOSE AND LOCK THIS GATE and PLEASE SHUT GATE. The IP verified the findings and stated, There's no way [Resident 1] could have gotten over this fence. During an interview with the Director of Nursing (DON), on 6/7/24, at 2:40 PM, the DON stated, We are a locked facility. The fence surrounds the entire building, and the only way in or out is through the locked gate. The DON stated Resident 1 was ambulatory. The DON stated before the incident Resident 1 wanted to go to his daughter's house approximately 25 miles from the facility. The DON stated Resident 1 was observed standing near the entry gate watching visitors and staff in and out the facility. The DON stated only the facility staff had a key to the gate. The DON stated we searched for Resident 1 and looked for chairs, barrels against the fence, any methods for him to climb over the fence, and we did not find anything. The DON stated we determined Resident 1 was not in the facility and notified the Sheriff's department. The DON stated Resident 1 was found by Sheriff's department hiding in an orchard a mile from the facility. The DON stated Resident 1 had minor scratches and have healed in a week. The DON stated Resident 1 had cognitive issues and was not able to tell us how he got out. The DON stated we had some visitors leave the facility on 5/15/24 at about 7:40 PM he must have exited the facility when the visitors left. The DON stated facility staff had to be there to unlock the gate for the visitors to exit the facility. The DON stated more likely Resident 1 exited the facility with the visitors without facility staff noticing. During a review of the facility Policy and Procedure (P&P) titled, Elopements and Wandering Residents, dated 10/24, the P&P indicated, in part, Policy: This facility ensures that residents who exhibit wandering behavior and/or are risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. Elopement occurs when a resident leaves the premises or a safe area without authorization. and/or any necessary supervision to do so. Policy Explanation and Compliance Guidelines: The facility is equipped with door locks/alarms to help avoid elopements. Adequate supervision will be provided to help prevent accidents or elopements.

Based on observation, interview and record review, the facility failed to ensure services provided met professional standards of quality for one of 27 residents (Resident 28), when Resident 28 was not offered water to rinse her mouth after aerosol oral inhaler (a medication used to prevent difficulty breathing administered by way of inhalation both oral and nasal) administration as ordered by the physician. This failure had the potential for the inhaler medication to accumulate in Resident 28's mouth and placed Resident 28 at risk to developed oral thrush (fungal infection). Findings: During an observation on 3/13/24 at 8:37 a.m., in Resident 28's room, the Director of Staff Development (DSD) administered aerosol oral inhaler to Resident 28. The DSD did not offer Resident 28 water to rinse her mouth after medication administration. During a review of Resident 28's Order Summary Report, dated 3/13/24 indicated, . 2 puffs inhale orally . rinse mouth with water and spit back into cup after use . During a review of Resident 28's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 12/27/23, the MDS section C indicated Resident 28 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 12 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which indicated Resident 28 was moderately impaired. During an interview on 3/14/24 at 4:09 p.m. with the Director of Nursing (DON), the DON stated her expectation was for the DSD to follow physician's order and rinse Resident 28's mouth after aerosol inhaler medication administration to prevent oral thrush. During a review of the facility's policy and procedure (P&P) titled, Provision of Physician Ordered Services, dated 10/2022, indicated, . the purpose of this policy is to provide a reliable process for the proper and consistent provision of physician ordered services according to professional standards of quality . During a review of the Federal Drug Administration (FDA a government agency responsible for protecting public health by ensuring the safety, efficacy of human drugs) Highlights of Prescribing Information (PI), dated 4/2008, the PI for fluticasone propionate indicated, . for oral inhalation . localized infections: Candida albicans (thrush) infection of the mouth and throat may occur . advise patients to rinse the mouth following inhalation .

Based on observation, interview, and record review, the facility failed to ensure drugs were labeled with resident identifier and expiration date in accordance with the facility's policy and procedure Labeling Medications and Biological's (a substance such as vaccines or drugs derived from a living organism used for treatment) when one Fluticasone propionate salmeterol inhaler (medications used to treat respiratory disease, a mist or spray that the patient breathes in the nose or mouth) and one nasal spray ( liquid medicine spray into the nose) medication was stored in medication cart 1 without a resident identifier label (resident's name and date of birth ) and expiration date. This failure placed residents at potential risk for receiving the wrong medication and expired medications, which could lead to medication ineffectiveness and medication adverse reaction. Findings: During a concurrent observation and interview on 3/14/24 at 11:13 a.m. with the Infection Preventionist (IP), in front of the nurse's station, medication cart 1 stored one inhaler medication and one nasal spray medication without a resident identifier label and without an expiration date. The IP stated the inhaler and nasal spray medication should have been labeled with the resident name and expiration date to prevent giving the medication to the wrong resident and to ensure medication efficacy. During an interview on 3/14/24 with the Director of Nursing (DON), the DON stated her expectation was for the inhaler and nasal spray medication labeled with resident identifiers and expiration date. The DON stated inhalers and nasal spray medication without a resident identifier and expiration date placed residents at risk for medication error and residents receiving medications which are less effective. During a review of the facility's policy and procedure (P&P) titled, Labeling of Medications and Biological's, dated 2023, the P&P indicated, . all medications and biological will be labeled in accordance with applicable federal and state requirements and current accepted pharmaceutical principles and practices . labels for individual drug containers must include: the resident's name, the prescribing physician's name, the medication name (generic and/or brand name), the prescribed dose, strength, and quantity of the medication . the expiration date when applicable, the route of administration . labels for medications designed for multiple administrations (such as inhalers, eye drops), the label will identify the specific resident for whom it was prescribed .

Based on observation, interview, and record review, the facility failed to follow policy and procedure to monitor and maintain essential equipment in a safe operating condition for one of six residents, (Resident 4), when Resident 4's oxygen concentrator (a medical device to deliver oxygen) was not routinely monitored and maintained in accordance with facility policy and procedure. This failure had the potential for Resident 4's oxygen concentrator to break down and fail which could result in Resident 4 going without oxygen. Findings: During a concurrent observation and interview on 3/13/24 at 8:54 a.m. with Certified Nurse Assistant (CNA) 1, in Resident 4's room, Resident 4's oxygen concentrator had gray particles on the surface. CNA 1 stated the oxygen concentrator had a lot of dust and should be cleaned. CNA 1 stated maintenance was responsible to ensure the oxygen concentrator was clean. During a concurrent observation and interview on 3/14/24 at 12:15 p.m. with Licensed Vocational Nurse (LVN) 1 in Resident 4's room, LVN 1 opened the oxygen concentrator filter cover and LVN 1 stated the filter was not clean and had a lot of dust. LVN 1 stated the filter should be clean to ensure proper functioning. LVN 1 stated she did not know when the last time maintenance cleaned the filter. During an interview on 3/14/24 at 12:20 p.m. with Resident 4, Resident 4 stated she expected the oxygen concentrator used to deliver her oxygen was clean. Resident 4 stated she wanted her oxygen concentrator clean and properly maintained. During an interview on 3/14/24 at 4:27 p.m. with the Director of Nursing (DON), the DON stated the facility was expected to follow manufacturer instructions for use of the oxygen concentrator and to ensure it was well maintained. DON stated she would provide a copy of the maintenance log and IFUs for the oxygen concentrator but did not. During a review of the facility Oxygen Concentrator Policy and Procedure (P&P), dated 10/22, the P&P indicated Policy: The purpose of this policy is to establish responsibilities for the care and use of oxygen concentrators . 5. Care of the Concentrator: a. Follow manufacturer recommendations for the frequency of cleaning filters . c. Nurse Responsibilities: . iv. The main body cabinet should be dusted when needed and can be wiped clean . During a review of the Brand Name Company Service & Technical Reference (Manual), undated, the Manual indicated, .Chapter 6. Maintenance 6.1 .Routine maintenance is very important in prolonging dependability and in reducing costly repairs. Long-term maintenance and regular checking of the filters helps assure the efficient operation of the unit .6.1.1 Filters Brand Name Company recommends. Replacing the Inlet Filter every two (2) years. During a review of the facility Resident -Care Equipment Policy and Procedure (P&P), dated 10/22, the P&P indicated Policy: Resident-care equipment can be a source of indirect transmission of pathogens (an organism causing disease). Reusable resident-care equipment will be cleaned and disinfected in accordance with current Centers for Disease Control (CDC) recommendations in order to break the chain of infection . 3. Staff shall follow established infection control principles for cleaning . j. Follow manufacturer recommendations for cleaning equipment.

Based on observation, interview, and record review, the facility failed to follow their grievance policy and procedure for five of 15 sampled residents (Residents 18, 27, 28, 37, and 39) when the facility did not ensure Resident 18, 27, 28, 37 and 39 were able to submit grievances anonymously. This failure resulted in Residents 18, 27, 28, 37, and 39 not able to exercise their rights to submit grievances anonymously regarding the facility and their care and could negatively affect their pyschosocial well-being. Findings: During the resident council meeting on 3/14/24 at 9:10 a.m. with Residents 18, 27, 28, 37, and 39, Residents 18, 27, 28, 37, and 39 stated they did not know how to file anonymous grievances. Resident 39 stated he did not know how to submit grievances anonymously. During an interview on 3/14/24 at 4:23 p.m. with the Social Services Director (SSD), the SSD stated residents must ask staff members for grievance forms. The SSD stated he kept grievance forms in his office, in a drawer behind the nurses' station and in a drawer locked in the Activities Director's (AD) office. During a concurrent observation and interview on 3/14/24 at 4:32 p.m. with the AD in the AD's office, the AD stated she kept the grievance forms locked in the drawer in her office. The AD opened the large drawer which contained the grievance forms. During an interview on 3/14/24 at 4:35 p.m. with the SSD, the SSD stated the facility did not ensure residents were able to file grievances anonymously without staff intervention since residents must ask staff members for the grievance forms. The SSD stated it was important for residents to have a truly anonymous process to file a grievance. The SSD stated residents would be afraid to file a grievance against the facility or a staff if residents had to ask staff for the grievance forms. During a review of the facility's policy and procedure (P&P) titled, Resident and Family Grievances, dated 10/2023, the P&P indicated . 9. A grievance may be filed anonymously .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain an accurate medical record consistent with professional standards and practices for four of 10 sampled residents (Resident 1, 4, 13, and Resident 34) when Resident 1, 4, 13, and 34's 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. These failures resulted in a medical record that did not reflect Resident 1, 4, 13, and 34's treatments for end-of-life care and services. Findings: During a concurrent interview and record review on 3/14/24 at 5:11 p.m. with Medical Records Director (MRD), Resident 1's POLST, dated 8/2/23 was reviewed. MRD stated Resident 1's POLST was not completed. MRD stated Resident 1's POLST was missing all the physician's information, which included the physician's name, physician's address, physician's phone number, physician's license number and the physician's signature. MRD stated the Nurse Practitioner (NP) and Physician Assistant (PA)'s name was missing, the preparer of the POLST's name, title and phone number were missing, and Resident 1's additional contact information which included a name, phone number, and relationship to the resident were also missing. The MRD stated Resident 1's POLST should have been completed in the event Resident 1 gets transferred to another facility, the receiving facility would have the information they need to ensure Resident 1's POLST were followed. During a review of Resident 1's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 3/15/24, the AR indicated Resident 1 was admitted on [DATE] with diagnoses of acute kidney failure (a condition where the kidneys suddenly cannot filter waste from the blood), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities), and schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 2/13/24, the MDS section C indicated Resident 1 had a 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 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which indicated Resident 1 was unable to complete the interview due to severe impairment. During a review of Resident 4's Electronic Medical Record (EMR), on 3/14/24 at 11:22 a.m. Resident 4's EMR Profile indicated Resident 4's Code Status (means the type of emergent treatment a person would or would not receive if their heart or breathing were to stop) was Full Code (if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive.). Resident 4's Care Plan indicated Resident 4's Code Status was Do Not Resuscitate (DNR- a legal document that means a patient has decided not to have cardiopulmonary resuscitation a lifesaving procedure when a patients heartbeat stops) performed and would be allowed to die naturally only if their heart stops beating and/or they stop breathing). During a review of Resident 4's admission Record (AR), dated 3/14/24, the AR indicated Resident 4 was admitted on [DATE] with diagnoses of seizures (sudden, uncontrolled body movements and changes in behavior that occur because of abnormal electrical activity in the brain.), altered mental status, obesity (overweight) due to excess calories, type 2 diabetes mellitus (a disease in which the body does not control the amount of glucose (a type of sugar) in the blood and the kidneys make a large amount of urine), need for assistance with personal care. During a review of Resident 4's MDS dated 1/30/24, the MDS Section C indicated Resident 4 had a BIMS (Brief Interview for Mental Status - a test given by medical professionals to determine cognitive understanding on a scale of 1-15) score of 12 out of 15 which indicated Resident 4 was moderately impaired. During a concurrent interview and record review on 3/14/24 at 11:50 a.m. with the MRD, Resident 4's EMR was reviewed. The MRD stated the EMR indicated Resident 4's code status was Full Code and compared to the paper chart which indicated Resident 4's code status was Do Not Resuscitate. The MRD stated Resident 4's code status in the EMR and paper chart did not match. The MRD stated Resident 4's code status should match to ensure Resident 4's life sustaining treatment were followed according to Resident 4's preference. During an interview on 3/14/24 at 11:54 a.m. with the facility DON, DON stated it is her expectation that nursing staff refer to the resident profile in the EMR to confirm resident code status and that resident medical records are maintained per facility policy. During a concurrent interview and record review on 3/14/24 at 5:11 p.m. with MRD, Resident 13's POLST, dated 3/13/24 was reviewed. MRD stated Resident 13's POLST was incomplete. The MRD stated Resident 13's POLST was missing the physician's phone number. The MRD stated in the event Resident 13 needs to be transferred to another facility and the POLST was incomplete the receiving facility would not have the physician contact information to verify Resident 13's life sustaining treatment wishes. During a review of Resident 13's AR, dated 3/15/24, the AR indicated Resident 13 was admitted on [DATE] with diagnoses of respiratory failure (a serious condition that occurs when the lungs cannot get enough oxygen into the blood or remove enough carbon dioxide [a waste gas] from the blood), 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), epilepsy (a seizure [a burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements, behaviors, sensations, or states of awareness] disorder), chronic kidney disease (a condition when the kidneys suddenly are unable to filter waste products from the blood), and bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs). During a review of resident 13's MDS, dated 1/25/24, the MDS section C indicated Resident 13 had a BIMS score of 99, which indicated Resident 13 was unable to complete the interview due to severe impairment. During a concurrent interview and record review on 3/14/24 at 5:11 p.m. with MRD, Resident 34's POLST, dated 1/11/24 was reviewed. The MRD stated Resident 34's POLST was not completed. The MRD stated the physician's printed name and phone number were missing. The MRD reviewed Resident 34's paper chart and stated the preparers information, and the additional contact information were not completed. The MRD stated the physician's information, additional contact information and preparer's information should have been completed. During a review of Resident 34's AR, dated 3/15/24, indicated Resident 34 was admitted on [DATE] with diagnoses of hemiplegia (paralysis [the loss of the ability to move and sometimes to feel anything] of one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) following cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), 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), acute respiratory failure (a serious condition that occurs when the lungs cannot get enough oxygen into the blood or remove enough carbon dioxide [a waste gas] from the blood), blindness, and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities). During a review of Resident 34's MDS, dated 1/18/24, the MDS sections C indicated Resident 34 had a BIMS score of 15, which indicated Resident 34 was cognitively intact. During a review of the job description (JD) titled, Medical Records Clerk, dated 2020, the JD indicated, . ensures resident records are properly completed, assembled, coded, etc., before filing . During a review of the facility's policy and procedure (P&P) titled, Documentation in Medical Record, dated 10/22, indicated, . licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy. documentation shall be accurate, relevant, and complete, containing sufficient details about the resident's care and/or responses to care . sign each entry with name and credentials of the person making the entry .

Based on observation, interview, and record review the facility failed to store, prepare, and serve food in accordance with the facility's policy and procedure and professional standards for food safety when: 1. [NAME] and gray particles were found in the windowsill (ledge on bottom of window) next to the food preparation sink. 2. [NAME] build up was found on the exterior of the dish washing machine. 3. The ice machine and food preparation sink had no air gaps (a vertical space usually one inch or more between the end of a pipe or faucet and the top of a sink which creates a separation between the water supply and contaminated water). 4. The temperature of the dish washing machine was under the minimum 120° Fahrenheit (F- unit of measurement) requirement. 5. Oven mitts used to handle hot foods were soiled with orange and brown grime and debris. 6. Food stored in the resident's refrigerator was not labeled with resident's name and use-by-date (the last day for the consumption of food item while at peak quality). These failures had the potential to cause cross-contamination and food borne illness to residents. Findings: 1. During an observation on 3/12/24 9:26 p.m. in the kitchen, brown and gray particles were found on a windowsill which was above the food preparation sink. During an interview on 3/13/24 2:55 p.m. with the Registered Dietitian (RD), the RD stated the dirt and dust on the windowsill had the potential to contaminate (to make dirty) food prepared in the sink below it. The RD state the windowsill should have been cleaned daily. During a concurrent interview and record review on 3/15/23 at 3:30 p.m. with the Certified Dietary Manager (CDM), the facility's policy and procedure (P&P) titled, Sanitation Inspection, dated 10/2022 was reviewed. The P&P indicated, . 1. All food service areas shall be kept clean, sanitary, free from litter, rubbish . 2. The department shall establish a sanitation program for food services based on applicable state and federal requirements . 4. Sanitation inspections will be conducted in the following manner: . b. weekly: The dietary manager shall inspect all food services weekly to ensure the areas are clean and comply with sanitation and food service regulations . The CDM stated dirt on the windowsill next to the food preparation sink did not follow the facility's policy. The CDM stated the dirt and debris on the windowsill could have contaminated the food prepared in the sink. During a review of the Food Code U.S Food and Drug Administration, dated 2022, indicated, . 4-602.13 Nonfood-Contact Surfaces. The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms (small germs which may cause illness) which employees may inadvertently (without meaning to) transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests . 2. During an observation on 3/12/24 at 9:26 p.m. in the kitchen, white sediment build-up was found on the exterior of the dish washing machine. During an interview on 3/13/24 2:55 p.m. with the RD, the RD stated, the white build up on the dish washer should have been cleaned. The RD stated no build up should have been present on the dish washer; bacteria (germs which could lead to illness) could grow in the white build up and contaminate the dishes. During a concurrent interview and record review on 3/15/23 at 3:30 p.m. with the CDM, the facility's P&P titled, Sanitation Inspection, dated 10/2022 was reviewed. The P&P indicated, . 1. All food service areas shall be kept clean, sanitary, free from litter, rubbish . 2. The department shall establish a sanitation program for food services based on applicable state and federal requirements . 4. Sanitation inspections will be conducted in the following manner: . b. weekly: The dietary manager shall inspect all food services weekly to ensure the areas are clean and comply with sanitation and food service regulations . The CDM stated the white build up on the dish washer did not follow the facilities policy. The CDM stated the buildup could have caused bacterial growth on the dish washing machine. During a review of the Food Code U.S Food and Drug Administration, dated 2022, indicated, . 4-602.13 Nonfood-Contact Surfaces. 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 . 3. During an observation on 3/12/24 at 9:26 a.m. in the kitchen, no air gap was found in the food preparation sink. During concurrent observation and interview on 3/13/24 11:15 a.m. with Plant Operations Supervisor (POS) in the kitchen, the POS stated the food preparation sink had no air gap. The POS stated without an air gap, the sewage water could back up into the sink and contaminate the food. During concurrent observation and interview on 3/13/24 11:15 a.m. with the POS in the break room, the POS stated the ice machine had no air gap. The POS stated without an air gap in the ice machine the sewage water could back up and contaminate the residents' ice. During an interview on 3/13/24 at 2:29 p.m. with RD, the RD stated the food preparation sink and ice machine did not have an air gap. The RD stated water could backflow from the sewer and contaminate residents' food. During an interview and record review on 3/15/23 at 3:30 p.m. with CDM, the facility's policy and procedure (P&P) titled, Sanitation Inspection, dated 10/2022 was reviewed. The P&P indicated, . 1. All food service areas shall be kept clean, sanitary, free from litter, rubbish . 2. The department shall establish a sanitation program for food services based on applicable state and federal requirements . 4. Sanitation inspections will be conducted in the following manner: . b. weekly: The dietary manager shall inspect all food service areas weekly to ensure the areas are clean and comply with sanitation and food service regulations . the CDM stated the ice machine and food preparation sink should have an air gap installed to prevent water backflow from the sewage. The CDM stated the facility did not follow the facility's policy and procedure. During a review of the Food Code U.S Food and Drug Administration, dated 2022, indicated, . 5-202.13 Backflow Prevention, Air Gap. During periods of extraordinary demand, drinking water systems may develop negative pressure (when water flows in the opposite direction) in portions of the system. If a connection exists between the system and a source of contaminated (dirty) water during times of negative pressure, contaminated water may be drawn into and foul (to make dirty) the entire system. Standing water in sinks . and other equipment may become contaminated with cleaning chemicals or food residue . 4. During an observation on 3/12/24 at 9:26 a.m. in the kitchen, the dish washing machine had a temperature of 110 ° Fahrenheit (F). During a concurrent observation and interview on 3/12/23 at 2:00 p.m. in the kitchen with CDM, the dish washer's temperature gauge was at 100° F. The CDM stated the temperature of the dishwasher should have been at a minimum of 120° F but it was only reaching 100° F. During a concurrent observation an interview on 3/12/23 at 8:35 a.m. with cook (CK) 1 in the kitchen, CK 1 was washing plates in the dishwasher. CK 1 stated the temperature displayed on the dishwasher was 100 °F. CK 1 stated the temperature should have been at 120 ° F for the dishwasher to be most effective. CK 1 stated a temperature under 120°F may not thoroughly clean the dishes. During an interview on 3/13/24 at 2:57 p.m. with RD, the RD stated the dish washer temperature should have been between 120°F to 140 °F. The RD stated when the temperature does not reach the minimum of 120, it could lead to dishes not sanitized properly. During a concurrent interview and record review on 3/15/23 at 3:30 p.m. with CDM, the facility's P&P titled, Dishwashing Policy, dated March 2010 was reviewed. The P&P indicated, . 7. The operator will check temperatures using the machine gauge with each dishwashing machine cycle and will record the results in a facility approved log. The operator will monitor the gauge frequently during dishwashing machine cycle. Inadequate (not enough) temperatures will be reported to the supervisor and corrected immediately . CDM stated having the dishwasher under 120° F did not follow the facility's policy. CDM stated having the temperature under 120° F could have prevented dishes from being thoroughly cleaned. CDM stated staff should not have been washing dishes with the temperature under 120 ° F and they should have reported any temperature below the minimum to her. CDM stated kitchen staff did not do frequent checks of the temperature per policy. During a review of the Food Code U.S Food and Drug Administration, dated 2022, indicated, . 4-501.15 Warewashing (dishwashing) Machines, Manufacturers' Operating Instructions. (A) A warewashing machine and its auxiliary (supporting) components shall be operated in accordance with the machine's data plate and other manufacturer's instructions . During a review of the dishwasher's Installation & Operating Instructions dated 12/05/2007, the form stated the dishwasher's required minimum temperature was 120° F. 5. During an observation on 3/12/24 at 9:26 a.m. in the kitchen, dietary staff used oven mitts covered in orange and brown debris. During an interview on 3/13/24 at 2:52 p.m. with RD, RD stated dietary staff should not use dirty or soiled oven mitts to prevent food contamination. RD stated the oven mitts should have been cleaned at the end of each day. During an interview on 3/15/23 at 1:48 p.m. with CDM, CDM stated dietary staff should not use soiled oven mitts. The CDM stated the oven mitts should have been cleaned once a day to prevent cross contamination from other foods being handled. During a review of the facility's P&P titled, Sanitation Inspection dated 10/2022, indicated, . 1. All food service areas shall be kept clean, sanitary, free from litter, rubbish . 2. The department shall establish a sanitation program for food services based on applicable state and federal requirements . 4. Sanitation inspections will be conducted in the following manner: . b. weekly: The dietary manager shall inspect all food service areas weekly to ensure the areas are clean and comply with sanitation and food service regulations . During a review of the Food Code U.S Food and Drug Administration, dated 2022, indicated, . 4-601.11 equipment food-contact surfaces and utensils shall be clean to sight and touch. Microorganisms may be transmitted from a food to other foods by utensils, cutting boards, thermometers, or other food-contact surfaces . 6. During an observation on 3/12/24 at 2:16 p.m. in the break room the resident's refrigerator stored a food item not labeled with a resident's name and used by date. During an interview on 3/13/24 at 2:35 p.m. with RD, the RD stated food stored in the resident's refrigerator should be labeled with resident's name and used by date to prevent giving the food to the wrong resident and to ensure food quality. During an interview on 3/15/24 at 9:48 a.m. with Certified Nursing Assistant (CNA) 5, CNA 5 stated the first and last name must be on the resident's personal food stored in the resident's refrigerator to prevent giving the food to the wrong patient. During an interview on 3/15/24 at 1:51 p.m. with CDM, the CDM stated resident food item stored in the resident's refrigerator should be labeled with resident's name and used by date to prevent giving the food to the wrong resident and to ensure food quality. During a review of the facility's P&P titled, Food brought in by Family/Visitors dated 03/2022, indicated, . 5. Food that is left with the resident to consume later is labeled and stored in a manner that is clearly distinguishable from facility-prepared food . b. [Food] containers are labeled with resident's name, the item and the 'use by' date .

Based on observation, interview, and record review, the facility failed to provide a clean and safe environment for residents, staff and the public when: 1.The kitchen dry storage floor had areas of brown stains, missing and cracked linoleum, exposing the cement underneath with accumulation of dark gray debris. 2.The facility floors in the common areas and resident rooms, had black-colored stains, uneven surfaces, cracked linoleum with accumulation of black and brown debris and missing baseboards. This failure to ensure the physical environment was maintained in a safe, clean, and sanitary manner as evidenced by multiple contact surfaces in disrepair placed residents, staff, and the public at potential risk for falls and cross contamination (the process by which bacteria are unintentionally transferred from one substance or object to another with harmful effect) which could lead to foodborne illness (caused by food contaminated with bacteria). Findings: 1. During an observation on 3/12/24 at 9:26 a.m. in the kitchen's dry food storage room, the floor had multiple areas of brown stains, missing and cracked linoleum, exposing the cement underneath with accumulation of dark gray debris. During an interview on 3/13/24 at 11:21 a.m. with Certified Dietary Manager (CDM), the CDM stated the floor was difficult to clean because of the missing and cracked linoleum and which should have been repaired. The CDM stated the damaged floor was unsanitary and could contaminate the food stored in the dry food storage room. During an interview on 3/13/23 at 11:23 a.m. with Plant Operations Supervisor (POS), the POS stated the damaged floor in the dry food storage room should have been repaired. The POS stated having dirty uncleanable flooring could have contaminated residents' food. During an interview on 3/13/24 at 2:43 p.m. with Registered Dietitian (RD), the RD stated the damaged floor in the dry food storage room should have been repaired to prevent cross contamination of food stored in the dry food storage room. During a review of the facility's policy and procedure (P&P) titled, Sanitation Inspection dated 10/2022, the P&P indicated, . 1. All food service areas shall be kept clean, sanitary, free from litter, rubbish . 2. The department shall establish a sanitation program for food services based on applicable state and federal requirements . 4. Sanitation inspections will be conducted in the following manner: . b. weekly: The dietary manager shall inspect all food service areas weekly to ensure the areas are clean and comply with sanitation and food service regulations . During a review of the Food and Drug Administration (FDA) Food Code, dated 2022, indicated, 6-101.1 floors shall be smooth, durable, and easily cleanable for areas where food establishment operations are conducted . Floors, walls, and ceilings that are constructed of smooth and durable surface materials are more easily cleaned . During a review of the facility Facility Responsibilities Policy and Procedure (P&P), dated 10/23, the P&P indicated Policy: It is the policy of this facility to uphold and comply with the facility responsibilities . 16. Safe Environment. The resident has a right to a safe, clean, comfortable, and homelike environment . b. housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior . 2. During an observation on 3/13/24 at 2:27 p.m. the flooring throughout the facility had some areas of uneven surfaces, missing baseboards, and cracked linoleum with accumulation of black and brown debris in the cracks and floor edges with the missing baseboards. During an interview on 3/14/24 at 10:43 a.m. with the POS, the POS stated he would not find it acceptable if the flooring in his house looked like the facility floors. The POS stated he was not aware of any resident or staff complaint of safety. During a concurrent observation and interview on 3/13/24 at 3:29 p.m. with the facility Infection Preventionist (IP), the IP stated part of her duties as an Infection Preventionist was to conduct facility rounds to ensure the facility was free of potential hazard and infection control concerns. The IP stated The floors were old, there is supposed to be a plan for remodeling the floor. The IP stated she was aware the kitchen dry food storage room needs new linoleum and should have been repaired. The IP stated the uneven floor surfaces could cause falls for residents and staff. The IP stated clean floors are important to prevent the spread of germs and residents getting sick, so they don't contaminate other locations. During an interview on 3/15/24 at 1:56 p.m. with the facility Administrator (ADM), the ADM stated she was aware of the damage flooring in the facility and should have been repaired to promote a homelike environment and safety for the residents and staff. During a review of the facility Facility Responsibilities Policy and Procedure (P&P), dated 10/23, the P&P indicated Policy: It is the policy of this facility to uphold and comply with the facility responsibilities . 16. Safe Environment. The resident has a right to a safe, clean, comfortable, and homelike environment . b. housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of six sampled Certified Nursing Assistant (CNA) 1 met the specific certification requirements when CNA 1 was working in the facility without an active CNA certification. This failure had the potential for Residents not being provided adequate and quality care according to their needs. Findings: During a concurrent interview and record review on [DATE] at 11:15 a.m. with the Director of Nursing (DON), the facility document titled, Active Employees (AE) dated [DATE] was reviewed. The AE indicated, CNA 1 ' s Certified Nursing Certificate had an expiration date of [DATE]. The DON stated CNA 1 ' s certificate expired on [DATE] and CNA 1 was not scheduled to work until her certificate was active. During a review of the facility document titled CNA NOC Shift [DATE], the document indicated, CNA 1 was on the schedule to work on [DATE], [DATE], [DATE] [DATE], and [DATE] for the night shift. During a review of the facility document titled Daily Assignment Sheet (DAS), the DAS indicated CNA 1 was scheduled to work on [DATE], [DATE],[DATE],[DATE], and [DATE]. During a telephone interview on [DATE] at 5 p.m., with Director of Staff Development (DSD), the DSD stated she was responsible to ensure all CNA certifications were active, monitors certifications upcoming expiration dates and help CNAs with renewals. The DSD stated, I was not aware the certificate for CNA 1 was going to expire on [DATE] The DSD stated it was not standard practice to have a CNA providing care to residents without an active certificate. During telephone interview on [DATE], at 10 a.m., with the DON, the DON stated CNA 1 worked for 5 days without an active certificate. The DON stated it was her responsibility to monitor the status of licenses and certificates for all employees. The DON stated CNA without an active certificate should have not been scheduled to work and providing care to residents. The DON stated we did not follow our policy & procedure for ensuring CNAs certificate were active. During a telephone interview on [DATE], at 10:34 a.m., with CNA 1, CNA 1 stated she worked on [DATE]-[DATE] on night shift without an active certificate. CNA 1 stated she should have not work without an active CNA certificate. CNA 1 stated I assumed my certificate was active. During a telephone interview on [DATE] at 1:20 p.m., with Administrator (ADM), the ADM stated CNA 1 ' s certificate expired on [DATE]. The ADM stated CNA 1 should have not been scheduled to work and providing care to residents. The ADM stated she was responsible to provide oversight to the DSD to ensure the DSD monitors CNAs certification status. The ADM stated she was responsible for the oversight to ensure staff were working in compliance with the standards of practice to provide safe and quality care for all residents. During a review of the facility ' s policy and procedure (P&P) titled, License Verification dated 2023, the P&P indicated, All personnel that require a license or certification shall be verified through the appropriate issuing agency .The Director of Staff Development or designees is responsible for maintaining and ensuring the validity .and current status of individual certification/licensure .Any licensed/certified employee is responsible for submitting verification of licensure/certification renewal to Human Resources prior to expiration. During a review of the facility ' s Job Description (JD) titled, Certified Nurse Assistant dated 2023, the JD indicated, The primary purpose of your job position is to provide each of your assigned residents with routine daily nursing care and services in accordance with the residents assessment and care plan .Attend and participate in scheduled training and educational classes to maintain current certification as a Nursing Assistant .Must be a licensed Certified Nursing Assistant in accordance with laws of the state . During a review of the facility ' s JD titled, Director of Nursing undated, the JD indicated, Administers nursing programs in long term care facility to maintain standards of patient care and advises medical staff, department heads and administrators in matters related to nursing services .Performs personnel management function such as establishing personnel qualification requirements .Supervises all employees in the Nursing Department . Is responsible for the overall direction and evaluation of this unit Responsibilities include .assigning and directing work . During a review of the facility ' s JD titled, Director of Staff Development undated, the JD indicated, Plans and conducts orientation and program for nonprofessional nursing personnel by performing the following duties .Assists certified nursing assistants with the re-certification process through the Department of Health .CNA monthly work schedule .

During an observation, interview, and record review, the facility failed to maintain a functioning communication system (call light system-an alerting device used by residents to request assistance from nursing staff) for 17 residents bed (3 C,4 B, 7 D, 9 A,B,D 10 C,D 11 A,B,C 12 A,B,C 14 A,B,C) out of 46 residents bed when the patient call light system warning lights above residents doorway and monitoring panel located in the nurses station to indicate when patients have perceived needs requiring attention were not functioning properly. This failure resulted for residents in the facility not able to call for help and receive immediate assistance from nursing staff which placed residents ' health and safety at risk. Findings: During an interview on 1/16/24 at 10:10 a.m., with Maintenance Supervisor (MS), the MS stated he conducted daily inspections for all the call lights in residents ' room for proper functioning. The MS stated when residents pressed the call light button, the warning lights above resident ' s doorway and the monitoring panel located in the nurse ' s station must turn on. During a concurrent observation and interview on 1/16/24 at 11 a.m., with the Administrator (ADM) and the Director of Nursing (DON), the ADM and the DON checked all call lights assigned to each resident ' s bed for proper functioning. The ADM and DON pressed the call light button for beds 3 C,4 B, 7 D, 9 A, B, D 10 C, D 11 A, B, C 12 A, B, C and 14 A, B, C and the warning lights above resident ' s doorway and monitoring panel located in the nurse ' s station did not turn on. The AMD and the DON stated the call lights were not functioning properly. The ADM and the DON stated the call light system should function properly for resident to call for assistance from facility staff. During an interview on 1/16/24 at 11:45 a.m., with Certified Nurse Assistant (CNA) 1. CNA 1 stated he was not aware the call lights were not functioning. CNA 1 stated the call lights should have been functioning properly for residents to request assistance from facility staff. During an interview on 1/16/24 at 11:52 a.m., with the Licensed Vocational Nurse (LVN) 2, LVN 2 stated she was not aware the call lights were not functioning. LVN 2 stated the maintenance were responsible to ensure the call lights were functioning for residents to be able to request assistance from nursing staff and for nursing staff to meet residents needs. During an interview on 1/16/24 at 12:15 p.m., with the DON, the DON stated 17 call lights were not functioning properly. The DON stated the broken call lights placed residents at risk for falls and delay in care. During an interview on 1/16/24 at 12:33 p.m., with the MS, the MS stated he checked warning lights above the resident ' s doorway for proper functioning this morning but did not check the monitoring panel at the nurse ' s station. The MS stated he did not conduct a detailed inspection of the call light system and should have. During an interview on 1/16/24, at 1:00p.m. with the Plant Supervisor Environment (PSE), the PSE stated it was important for call light system to functioning properly for residents to call for assistance from nursing staff. The PSE stated he was responsible to ensure the MS was performing daily inspection of the call light system for proper functioning. During an interview on 1/16/24, at 1:10 p.m., with ADM, the ADM stated he did not know how often the MS checks the call light system. The ADM stated the MS should check the call light system weekly. The ADM stated this was the first time the call light system was not functioning properly. During a review of the facility ' s policy and procedure (P&P) titled, Call Lights dated 11/2022, the P&P indicated The purpose of this policy is to ensure the facility is adequately equipped with a call light at each residents ' bedside and bathing facility to allow resident to call for assistance. Call lights directly relay to a staff member or centralized location to ensure appropriate response Staff will report problems with a call light or the call system immediately to the supervisor and/or maintenance director and will provide immediate or alternative solutions . Ensure the call system alerts staff members directly or goes to a centralized staff work area .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents was treated with respect and dignity for one of three sampled residents (Resident 2) when staff shaved Resident 2 in the hallway without providing privacy. This failure violated Resident 2's right to be treated with respect and dignity and had the potential to cause embarrassment. Findings: During a review of Resident 2's face sheet titled, admission Record, (document containing resident personal information), undated, the face sheet indicated Resident 2 was admitted to the facility on [DATE], with diagnoses which included, cerebral infarction (stroke caused by disrupted blood flow to the brain), urinary tract infection (infection in any part of the urinary system [kidneys, bladder, or urethra]), contracture (permanent tightening of the muscles, tendons, skin, and nearby tissues that causes deformity of the joints), type 2 diabetes mellitus (a long-term metabolic disorder that is characterized by high blood sugar levels), and Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination). During a review of Resident 2's Minimum Data Set (MDS-a resident assessment tool used to identify resident cognitive [pertaining to reasoning memory and judgement] and physical functional level) assessment, dated 2/9/23, the MDS indicated Resident 2's Brief Interview for Mental Status (BIMS-screening tool used in nursing home to assess cognition) indicated Resident 2 was severely impaired. During a concurrent observation and interview on 5/3/23, at 10:28 a.m., with Certified Nursing Assistant (CNA) 4, in the west wing hallway, between room [ROOM NUMBER] and the laundry room, CNA 4 shaved Resident 2 without providing privacy. CNA 4 stated, Resident 2's room did not have a bathroom to shaved Resident 2. CNA 4 stated, Resident 2 was in room [ROOM NUMBER]C, and the residents in room [ROOM NUMBER] and 9 used the sink room located between room [ROOM NUMBER] and the laundry room to shaved. CNA 4 stated, the sink area could accommodate a wheelchair, but Resident 2 used a Geri-Chair (a large, padded chair, which reclines and transport seniors with limited mobility) and would not fit the sink room door. CNA 4 stated, she did not provide privacy to Resident 12 when she shaved Resident 12 in the hallway. During an interview on 5/3/23, at 2:34 p.m., with Licensed Vocational Nurse (LVN) 5, LVN 5 stated, Resident 12 should have not been shaved in the hallway to promote and maintain Resident 12's dignity. LVN 5 stated, residents in room [ROOM NUMBER] and 9 used the sink room to shave. LVN 5 stated, Resident 12's Geri Chair did not fit in the sink room door. LVN 5 stated, the CNA should have shaved Resident 12 in his room with curtains closed or during his showers to provide privacy. During an interview on 5/3/23, at 2:40 p.m., with the Director of Staff Development (DSD), the DSD stated, the sink room in the hallway was used to shaved residents to provide privacy. The DSD stated, CNA 5 should have shaved Resident 12 in his room and not in the hallway to maintain Resident 12's dignity. The DSD stated, dignity was an important right as a human being and does not matter if the person was alert or not. The DSD stated she would be embarrassed if she was exposed to others and while receiving care. During an interview on 5/3/23, at 3:52 p.m., with the Director of Nurses (DON), the DON stated, the expectations was for the CNAs to provide all residents with privacy during care and not use the hallway as a shaving area. The DON stated, shaving Resident 12 in the in the hallway in front of everybody was a dignity and privacy issue and was unacceptable. The DON stated, Resident 12 had the potential to be embarrassed. The DON stated, Resident 12 should have been shaved in his room with the curtains closed. During a review of the facility's policy and procedure (P&P), titled Promoting/Maintaining Resident Dignity, undated, the P&P indicated, .It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity . 1. All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights . 4. The resident's former lifestyle and personal choices will be considered when providing care . 9. Groom and dress residents according to resident preference . 12. Maintain resident privacy .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report a resident-to-resident altercation in accordance with the facility policy and procedure and state regulations for one of nine sampled residents (Resident 12), when Resident 12 and another resident had a witnessed altercation and was not reported to the State Licensing Agency. This failure resulted in delayed investigation of the alleged resident to resident abuse allegation and delayed of assessment and treatment for Resident 12's bruised right hand. Findings: During an observation on 5/1/23, at 11:34 a.m., in Resident 12's room, Resident 12 was lying in bed with a purple bruise on the right hand. During an observation on 5/2/23, at 11:32 a.m., in the facility lobby, Resident 12 was sitting in a wheelchair with a green and purple bruise on the right hand. Resident 12's bruise extended from the top right of the hand to the middle and ring finger. During a review of Resident 12's admission Record (AR- is a document that gives a patient's information at a quick glance which includes contact details, a brief medical history and the patient's level of functioning, along with patient preferences and wishes), dated 5/3/23, the AR indicated, Resident 12 was admitted to the facility on [DATE] with diagnosis of Residual Schizophrenia (an individual has suffered an episode of schizophrenia but there are no longer delusions, hallucinations, disorganized speech or behavior), Bipolar II Disorder (characterized by depressive and hypomanic episodes), Generalized Anxiety Disorder (severe, ongoing anxiety that interferes with daily activities) and Parkinson's Disease (a disorder that affects movement, often including tremors). During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool used to identify resident cognitive and physical functional level) assessment dated [DATE], indicated Resident 12's Brief Interview for Mental Status (BIMS-assessment of cognitive status for memory and judgement) assessment score of 10 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderate impairment, and 00-07 indicates sever impairment) which indicated Resident 12 had moderate cognitive impairment. During a review of Resident 12's Order Summary Report (OSR), dated 5/3/23, the OSR indicated, Resident 12 was not receiving anticoagulants (inhibiting the coagulation [process of liquid, especially blood, changing to a solid or semi-solid state] of the blood with side effects of severe bruising, prolonged nosebleeds, blood in the urine and blood in the stool). During an interview on 5/2/23, at 11:40 a.m., with Certified Nursing Assistant (CNA) 5, CNA 5 stated, she was familiar with Resident 12. CNA 5 stated, on 4/28/23, she noticed Resident 12 had a bruise on her right hand and notified the License Nurse. CNA 5 stated, she did not recall who the nurse was. During a concurrent observation and interview on 5/2/23, at 11:45 a.m.,with Licensed Vocational Nurse (LVN) 1, in the lobby, LVN 1 stated, Resident 12 had a green and purplish bruise to her right hand. LVN 1 stated, on 4/28/23 one of the CNA's at the facility reported to her Resident 12 and another resident were punching each other. LVN 1 stated, she reported the altercation incident to the Director of Nursing (DON), Resident 12's Physician and Responsible Party. LVN 1 stated, after she reported the incident to the DON, the DON took over the process. LVN 1 stated she did not report the altercation incident to the State Licensing Agency (SLA- a government agency which ensures healthcare facilities compliance with state licensing laws and federal regulations). During a review of Resident 12's Progress Notes, dated 4/28/23, at 7:23 p.m., the Progress Notes indicated, . At [5:30 p.m.] CNA reported to writer that CNA witnessed resident [Resident 22] hit peer [Resident 12] in dining room. No injuries were noted on either of residents . During an interview on 5/3/23, at 2:43 p.m., with the Director of Staff Development (DSD), the DSD stated, resident to resident altercation was a considered an abuse. The DSD stated, the CNA who witnessed the incident would report to the license nurse (LN) and provide a written statement of the incident. The DSD stated, the LN would complete an SOC-341 form (a form use to report suspected dependent elderly abuse) with the CNA statement attached and submit to the Long-Term Care Ombudsman (a government official who assist residents in long-term care facilities with issues related to day-to-day care, health, safety, and personal preferences) and SLA within 24 hours. The DSD stated the resident-to-resident altercation should have been reported to the SLA to ensure appropriate corrective actions had been taken to prevent further altercations. During a review SOC-341, dated 4/28/23, the SOC-341 indicated, . Victim [Resident 12] . TELEPHONE REPORT MADE TO [unchecked box] Local Ombudsman [unchecked box] Calif. Dept. of State Hospitals [unchecked box] Calif. Dept. of Developmental Services . WRITTEN REPORT Enter information about the agencies receiving this report . Agency Name CDPH [California Department of Public Health] . Date Faxed 5/3/23 . REPORTING PARTY . Name [DON] . INCIDENT INFORMATION . Date/Time of Incident(s) 4/28/2023 [5:30 p.m.] . REPORTED TYPES OF ABUSE . [checked box] Other . residents were punching into the air toward each other . During an interview on 5/4/23, at 3:47 p.m., with the DON, the DON stated, all the facility staff was a mandated reporter for abuse incident. The DON stated, the facility process for resident-to-resident altercation was for the facility to report the incident to the SLA within 72 hours for altercations without an injury. The DON stated, Resident 12's altercation with another resident happened on 4/28/23 and the SLA was not notified within the 72 hours timeframe. During a concurrent interview and record review, on 5/8/23, at 2:50 p.m., with the DON, State Operations Manual (SOM), dated 2/3/23 was reviewed. The SOM indicated . The facility must develop and implement written policies and procedures that . Ensure reporting of crimes occurring in federally-funded long-term care facilities . In repose to allegations of abuse, neglect, exploitation, or mistreatment, the facility must . Ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency . where state law provides for jurisdiction in long-term care facilities) . The facility's policy and procedure (P&P) titled Compliance with Reporting Allegation of Abuse/Neglect/Exploitation (undated) was reviewed, the P&P indicated, . The facility will identify events, occurrences, patterns, and trends that may constitute: Abuse: . which can include staff to resident abuse and certain resident to resident altercations . Procedure for Response and Reporting Allegations of Abuse/Neglect/Exploitation: Any owner, operator, employee, manager, agent, or contractor of the facility can report an allegation of abuse/neglect/exploitation to the abuse agency . The Administrator or designee will . Notify the appropriate agencies immediately; as soon as possible, but no later than 24 hours after discovery of the incident . Follow up with the appropriate agencies, during business hours, to confirm the report was received . The DON stated, Resident 12's altercation incident should have been reported to the SLA within 24 hours. The DON stated, the facility's P&P and the SOM was not followed.

Based on interview and record review, the facility failed to provide written notification to the Long-Term Care Ombudsman (LTCO- a person who routinely visits the facility and advocates for the residents) when one of two sampled residents (Resident 47) was transferred to the acute care hospital. This failure had the potential to result in Resident 47 not having an advocate who could inform them of their admission, transfer, and discharge rights and options. Findings: During a concurrent interview and record review, on 5/8/23, at 10:46 a.m., with the Director of Medical Records (DMR), Resident 47's Transfer Form (TF), dated 2/28/23 was reviewed. The DMR stated, he was unable to find documentation of LTCO notification when Resident 47 was transferred to the acute care hospital. The DMR stated, during the time when Resident 47 was transferred to the acute care hospital the facility did not have a Director of Social Services (DSS). The DMR stated, it was the responsibility of the DSS to notify the LTCO when Resident 47 was transferred to the acute care hospital. During an interview on 5/8/23, at 10:57 a.m., with the DSS, the DSS stated, the facility process when a resident transferred to the acute care hospital was for the DSS to complete the Transfer/Discharge notification form, provide the form to the LTCO and kept a copy of the form in resident's clinical record. During an interview on 5/8/23, at 11:17 a.m., with the LTCO, the LTCO stated, he was not notified by the facility when Resident 47 was transferred to the acute care hospital. The LTCO stated, the facility should have provided him a written notification when Resident 47 was transferred to the acute care hospital. During a concurrent interview and record review, on 5/8/23, at 12:03 p.m., with the DSS, Resident 47's TF, dated 2/28/23 was reviewed. The DSS stated, she was unable to find documentation of LTCO notification when Resident 47 was transferred to the acute care hospital. The DSS stated, the LTCO should have been notified when Resident 47 was transferred to the acute care hospital to be able to advocate for Resident 47. During a concurrent interview and record review, on 5/8/23, at 2:25 p.m., with the Director of Nursing (DON), Resident 47's TF, dated 2/28/23 was reviewed. The DON stated, she was unable to find documentation of LTCO notification when Resident 47 was transferred to the acute care hospital. The DON stated, the expectations was for the DSS to notify the LTCO when a resident was transferred to the acute care hospital and placed the LTCO notification in residents clinical record. The DON stated it was important to notify the LTCO when Resident 47 was transferred to the acute care hospital for the LTCO to provide the support and advocate for Resident 47 while in the acute care hospital. During a review of the facility's policy and procedure (P&P) titled, Transfer and Discharge, (undated), the P&P indicated, . Transfer refers to the movement of a resident from a bed in one certified facility to a bed in another certified facility when the resident expects to return to the original facility . The facility will maintain evidence that the notice was sent to the Ombudsman . Professional reference titled, CMS Issues Clarification of Notice Requirements to Long-Term Care Ombudsman when Resident is transferred or discharged from Long-Term Care Facility dated 7/24/17, (found at https://www.hallrender.com/2017/07/24/cms-issues-clarification-of notice requirements) indicated . On May 12, 2017, the Survey and Certification Group at Centers for Medicare and Medicaid Services (CMS) issued a memorandum, Implementation Issues, Long-Term Care Regulatory Changes . Clarification of Notice before Transfer or Discharge Requirements clarifying the requirements of the Final Rule regarding the timing for providing notice to the State Long-Term Care Ombudsman in the event a resident is transferred or discharged from the long term care facility. Facilities must immediately review and revise their discharge and transfer notice practices, policies and procedures . Emergency Transfers, when a resident is temporarily transferred on an emergency basis to an acute care facility, notice of the transfer may be provided to the resident and resident representative as soon as practicable . Copies of notices for emergency transfers must also still be sent to the Ombudsman .

Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS- assessment of healthcare and functional needs) assessment accurately reflected the resident's status for one of four sampled residents (Resident 23) when Resident 23 who was nonverbal and was coded as comatose (a state of deep unconsciousness for a prolonged period, the person's eyes will be closed and unresponsive to their environment) in the MDS assessment. These failures resulted in an inaccurate assessment of Resident 23's mental status and had the potential for Resident 23's needs to go unmet. Findings: During an observation on 5/1/23, at 10:30 a.m., Resident 23 was lying in bed with eyes open. Resident 23 did not respond when spoken to. During an observation on 5/1/23, at 12:48, in Resident 23's room, a nursing staff was feeding Resident 23 with a puree diet (food with a pudding-like consistency). During a review of Resident 23's MDS, dated 3/21/23, the MDS section B, (a section in the MDS which assessed hearing, speech, and vision), indicated Resident 23 was . Comatose . no discernable consciousness . During an observation on 5/3/23, at 9:41 a.m., Resident 23's eyes were open and was able to track (followed movement in front of eyes). During an interview on 5/3/23, at 9:56 a.m., with Licensed Vocational Nurse (LVN) 2, LVN 2 stated, Resident 23 since admission was nonverbal, but was alert and eat with assistance. During an interview on 5/3/23, at 11:00 a.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated, Resident 23 was not comatose, and respond to voice, movement, and pain. CNA 1 stated, Resident 23 was able to eat meals with assistance. During a concurrent interview and record review on 5/8/23, at 11:31 a.m., with the Minimal Data Set Nurse (MDSN), Resident 23's MDS section B, dated 3/21/23, was reviewed. The MDSN stated, Resident 23 was non-verbal and awake at times. The MDSN stated, the MDS indicated, Resident 23 was comatose. The MDSN stated, a comatose person could eat a pureed diet by mouth. The MDSN stated, the MDS was not accurate, and it was important to have an accurate MDS to properly care for and meet resident's needs. During a concurrent interview and record review on 5/8/23, at 11:40 a.m., with the MDSN, Resident 23's MDSs, dated 9/19/22, 12/19/22, and 3/21/23, were reviewed. The MDSN stated, all three MDSs indicated Resident 23 was comatose. The MDSN stated, the three MDSs were inaccurate. CMS (Centers for Medicare and Medicaid Services) Professional reference titled, Resident Assessment Instrument dated 10/18 (found at www.cms.gov) indicated, .The purpose of this manual is to offer clear guidance about how to use the Resident Assessment Instrument (RAI) correctly and effectively to help provide appropriate care. Providing care to residents with post-hospital and long-term care needs is complex and challenging work. Clinical competence, observational, interviewing, and critical thinking skills, and assessment expertise from all disciplined are required to develop individualized care plans . The RAI helps nursing home staff to look at residents holistically as individuals for whom quality of life and quality of care are mutually significant and necessary .B0100: Comatose . A pathological state in which neither arousal (wakefulness, alertness) nor awareness exists. The person is unresponsive and cannot be aroused; he/she does not open his/her eyes, does not speak, and does not move his/her extremities on command or in response to noxious stimuli (e.g., pain) . Coding Instructions . Code 0, no: if a diagnosis of coma or persistent vegetative state is not present during the 7-day look-back period. Continue to B0200 Hearing . Code 1, yes: if the record indicates that a physician, nurse practitioner or clinical nurse specialist has documented a diagnosis of coma or persistent vegetative state that is applicable during the 7-day look-back period. Skip to Section G0110, Activities of Daily Living (ADL) Assistance . Only code if a diagnosis of coma or persistent vegetative state has been assigned. For example, some residents in advanced stages of progressive neurologic disorders . may have severe cognitive impairment, be non-communicative and sleep a great deal of time; however, they are usually not comatose or in a persistent vegetative state, as defined here .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a person-centered comprehensive care plan was implemented timely for one of 23 sampled residents (Resident 30) when Resident 30 had a diagnosis of contractures (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) and had a physician order for a left hand splint (a device used to support the hand and wrist in best position while resting and to help reduce swelling and pain) with no implementation of a comprehensive care plan. This failure had the potential to result in Resident 30's care needs going unmet. Findings: During a review of Resident 30's face sheet, titled admission Record (document containing resident personal information), undated, the face sheet indicated Resident 30 was admitted to the facility on [DATE], with diagnoses which included, Hereditary and idiopathic (unknown cause) neuropathy (nerve problem that causes pain, numbness, tingling, swelling, or muscle weakness), contracture, muscle weakness, and abnormalities of gait (walking) and mobility. During a review of Resident 30's Minimum Data Set (MDS-a resident assessment tool used to identify resident cognitive [pertaining to reasoning memory and judgement] and physical functional level) assessment, dated 2/17/23, the MDS indicated Resident 30's Brief Interview for Mental Status (BIMS- screening tool used in nursing home to assess cognition) assessment score was 11 out of 15 (0-15 scale [0-6 severe cognitive deficit, 7-12 moderate cognitive deficit, 13-15 no cognitive deficit]) which indicated Resident 30 had a moderate cognitive deficit. During an observation on 5/1/23, at 10:45 a.m., in Resident 30's room, Resident 30 was lying in bed, and eating a pudding using her right hand. A hand splint was on her nightstand and a sign on the wall which indicated, Please put my resting hand splint [a device used to support the hand and wrist in best position while resting and to help reduce swelling and pain] on in the morning. Wear schedule up to 8 hours, discontinue splint if she shows any signs of skin breakdown, irritation, or pain and notify OT [Occupational Therapist]. Resident 30 stated, they never put the splint on me. Resident 30 pulled her blanket back and exposed her left hand which was significantly contracted. Resident 30 stated, she had a stroke and was unable to move her fingers. During an observation on 5/2/23, at 11:24 a.m., in Resident 30's room, Resident 30's hand splint was on top of the nightstand. Resident 30 was lying in bed and pulled up her left hand to show she did not have her hand splint on. Resident 30's left hand the thumb was fully contracted into the palm of her hand, the index and second finger were stiff with moderate contractures, the ring finger and pinkie had significant contractures and was unable to straighten any of her fingers. During a concurrent interview and record review on 5/3/23, at 2:15 p.m., with LVN 5, Resident 30's Order Summary Report, (ORS) dated 5/2023 was reviewed. the ORS indicated, .Resident to wear left resting hand splint for 8 hours per day, while awake, as contracture management. Please check for skin impairment and inform COTA (Certified Occupational Therapy Assistant) if changes occur . LVN 5 stated, the ORS was not followed, and nursing staff should have applied Resident 30's hand splint and assessed the skin underneath the splint for skin breakdown. Resident 30's Care Plan, (CP) was reviewed. LVN 5 stated, she was unable to find the Care Plan for Resident 30's left hand splint. LVN 5 stated, the CP for Resident 30's left hand splint should have been implemented to address Resident 30's left hand contractures. During a concurrent interview and record review on 5/8/23, at 1:35 p.m., with the DON, Resident 30's physician orders were reviewed. The DON stated, the physician's orders indicated Resident 30's left hand splint to be worn for 8 hours every day. The DON stated, the licensed nurse's responsibility was to ensure Resident 30's hand splint was applied according to physician's order and to assessed for skin breakdown underneath the splint. Resident 30's CP was reviewed. The DON stated, she was unable to find a CP for Resident 30's left hand splint. The DON stated, Resident 30's CP for left hand splint should have been implemented to address Resident 30's left hand contracture. The DON stated, the CP was important to provide individualized care to each resident. During a review of the facility's policy and procedure (P&P), dated 2022, the P&P indicated, . Comprehensive care plans . It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident . That includes measurable objectives and time frames to meet a residents medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment . The care planning process will include an assessment of the resident's strengths and needs . The comprehensive care plan will describe, at a minimum . The services that are to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being . Any services that would otherwise be furnished, but are not provided due to the resident's exercise of his or her right to refuse treatment . Any specialized services or specialized rehabilitation services the nursing facility will provide . Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made . 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 . Failure to formulate or follow the nursing care plan .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During a review of Resident 30's face sheet titled, admission Record, undated, the face sheet indicated Resident 30 was admitted to the facility on [DATE], with diagnoses which included, Hereditary and idiopathic (sudden onset and cause unknown) neuropathy (nerve problem that causes pain, numbness, tingling, swelling, or muscle weakness), contracture (permanent tightening of the muscles, tendons, skin, and nearby tissues that causes deformity of the joints), muscle weakness, abnormalities of gait (walking) and mobility. During a review of Resident 30's Minimum Data Set (MDS-a resident assessment tool used to identify resident cognitive [pertaining to reasoning memory and judgement] and physical functional level) assessment, dated 2/17/23, the MDS indicated Resident 30's Brief Interview for Mental Status (BIMS- screening tool used in nursing home to assess cognition) assessment score was 11 out of 15 (0-15 scale [0-6 severe cognitive deficit, 7-12 moderate cognitive deficit, 13-15 no cognitive deficit]) which indicated Resident 30 had a moderate cognitive deficit. During an interview on 5/3/23, at 9:31 a.m., with Resident 30, Resident 30 stated she had a urinary tract infection (UTI- infection in any part of the urinary system, the kidneys, bladder, or urethra) and had been on an antibiotic (drug used to treat infection caused by bacteria). Resident 30 stated, it was burning and felt hot when I peed. During a record review of Resident 30's urinalysis (UA) titled Lab Results Report, dated 4/17/23, the UA indicated, .Urine Clarity . Turbid [cloudy discolored urine] . Leukoesterase Urine [white blood cells in the urine which can be associated with infection] . 2+ . During a concurrent interview and record review on 5/8/23, at 10:23 a.m., with LVN 2, Resident 30's clinical record titled Progress Notes was reviewed. LVN 2 stated, Resident 30 had a UTI recently and had complained of burning during urination. LVN 2 stated, she was unable to find a documentation of an assessment performed by the license nurse of Resident 30's onset of burning during urination, which was a change in condition. LVN 2 stated, if there is no documentation [of the assessment], it didn't happen. LVN 2 reviewed Resident 30's clinical record titled Alert Note, dated 4/17/23, the alert note indicated, .MD in house seen patient gave new order for UA [Urinalysis (test of the urine to check for infection)] and send results when received also gave new order for [brand name of medication used to treat discomfort of UTI] 100mg PO [by mouth] TID [three times per day] X 3 days . LVN 2 stated, Resident 30's physician was at the facility on 4/17/23 and ordered a UA. LVN 2 stated, even though Resident 30's physician came to the facility; the LN was still responsible to perform an assessment and document the change in condition. LVN 2 stated, the change of condition assessment and documentation were very important for the nursing staff to know when Resident 30's symptoms started, what was the symptoms, and if the symptoms had improved to verify Resident 30's infection had been properly treated. During a concurrent interview, and record review on 5/8/23, at 11:05 a.m., with the DON, Resident 30's clinical record was reviewed. The DON stated, she was unable to find the LN assessment for the change in condition. The DON stated the expectations was for the LN to perform Resident 30's assessment for change in condition which included the onset of burning in urination, urine characteristics, current vital signs, and document the findings as soon as possible. The DON stated even though the physician was in the facility, the LN was still responsible to perform their own assessment. The DON stated, the change of condition assessment was not documented, then it was not done. The DON stated, the LN did not perform the job duties and responsibilities of accurate assessment and documentation for change of condition. During a review of the facility's document titled Job Description Manual . Licensed Vocational Nurse, undated, the job description indicated, .Charge Nurse . Conduct the daily nursing functions in accordance with Company, State, Federal and local rules, regulations and guidelines . Charts progress notes in an informative, factual manner that reflects the care administered as well as the resident's response to care . Follows established procedure for charting and reporting all reports . documents in progress notes any exceptions to residents condition . Accurately completes and is familiar with the forms used throughout the residents chart . Ensures that the progress notes are reflective of the care plan and that the approaches on the care plan are being followed . During a review of the facility's P&P titled, Nursing Services and Sufficient Staff, dated 2022, the P&P indicated, .It is the policy of this facility to provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident . The facility must ensure that licensed nurses have the specific competencies and skill sets . Providing care includes . assessing, evaluating, planning and implementing care plans and responding to resident's needs . 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 . Failure to formulate or follow the nursing care plan . Based on observation, interview, and record review, the facility failed to meet professional standards of quality for two of three sampled residents (Resident 18 and Resident 30) when: 1. Licensed Vocational Nurse (LVN 1) used an unapproved medication administration technique while using an insulin flex pen (a device used to inject insulin [hormone- regulatory substance made by the body to control blood sugar production]) during a medication pass observation. This failure placed Resident 18 at risk for dosing errors and had the potential for adverse side effects such as hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar). 2. License Nurse (LN) failed to perform a change of condition assessment and documentation for Resident 30's complained of burning with urination. This failure had the potential for Resident 30's change of condition not being addressed by the nursing staff which could lead to delayed in treatment and services. Findings: During a medication pass observation on 5/2/23, at 9:27 a.m., in Resident 18's room, LVN 1 administered Glargine (long acting insulin) 15 units (unit of measurement) SQ (subcutaneous - injection given in the fatty tissue, just under the skin) to Resident 18's right side abdomen using an insulin flex pen. LVN 1 did not prime (remove bubbles from the needle) the insulin pen before administering the insulin to Resident 18. During a review of the clinical record for Resident 18, the Face Sheet (a document with demographic, personal and medical information) undated, indicated Resident 18 had a diagnoses which included Type 2 Diabetes (a long-term metabolic disorder that is characterized by high blood sugar levels). The Physician Orders dated 5/23, indicated, Insulin Glargine inject 15 unit .two times a day related to Type 2 diabetes . During a concurrent interview and record review on 5/2/23, at 11:49 a.m., with LVN 1, the manufacturer's guidelines titled, Instructions for Use [Brand name] KwikPen undated indicated, .Read the instructions for use before you start .Prime before each injection .Priming means removing the air from the Needle and Cartridge that may collect during normal use. It is important to prime your Pen before each injection so that it will wok correctly. If you do not prime before each injection, you may get too much or too little insulin .To prime your Pen, turn the Dose Knob to select 2 units. Hold your Pen with the Needle pointing up. Tap the Cartridge Holder gently to collect air bubbles at the top . Continue holding your Pen with Needle pointing up. Push the Dose Knob in until it stops, and 0 is seen in the Dose window . LVN 1 stated, she was not aware of the need to prime the insulin pen prior to administration. LVN 1 stated she was not trained on how to prime the insulin pen upon hire. LVN 1 stated, per the manufacturer guideline the insulin pen should have been primed prior to administering to Resident 18 to ensure Resident 18 received the correct dose. During a telephone interview on 5/2/23, at 12:09 p.m., with the Pharmacist Consultant (PC), PC stated the main purpose of priming the insulin pen was to ensure air bubbles were removed and the residents received the accurate dose. During a concurrent interview and record review on 5/2/23, at 12:48 p.m., with Director of Staff Development (DSD), LVN 1's employee file was reviewed. DSD stated, there was no in-service training or skills check check to ensure LVN 1's competency for insulin pen use. DSD stated, the purpose of priming the insulin pen was to make sure the insulin was administered with the correct dose. During a concurrent interview and record review on 5/2/23, at 3:20 p.m., with Director of Nursing (DON), the facility policy titled, Medication Administration Subcutaneous Insulin dated 1/22 was reviewed. The Medication Administration Subcutaneous Insulin indicated, To administer subcutaneous insulin as ordered and in a safe, accurate and effective manner .Performing the safety test ensures that you get an accurate dose by .removing air bubbles .Check if insulin comes out of the needle tip .If no insulin comes out, the needle may be blocked. Change the needle and try again . DON stated, it was facility policy and the manufacturers guideline to prime the insulin pen prior to administration to ensure the correct dose was administered. DON stated, the facility did not have in-service training or skills check off for insulin pen administration. During a review of the facility Licensed Vocational Nurse job description undated was reviewed. The job description indicated, .Ability to administer medications and treatment timely and according to facility policy .

**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 30) received appropriate equipment to prevent further decline in mobility and range of motion when Resident 30 had a diagnosis of contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) and nursing staff failed to apply Resident 30's left hand splint (a device used to support the hand and wrist in best position while resting and to help reduce swelling and pain) according to physician's order. This failure resulted in the potential risk for Resident 30's left hand contracture to worsen, which could lead to further declined in mobility and range of motion, and increased dependence for activities of daily living. Findings: During a review of Resident 30's face sheet titled, admission Record,(AR- is a document that gives a patient's information at a quick glance which includes contact details, a brief medical history and the patient's level of functioning, along with patient preferences and wishes) undated, the face sheet indicated Resident 30 was admitted to the facility on [DATE], with diagnoses which included, Hereditary and idiopathic (sudden onset and cause unknown) neuropathy (nerve problem that causes pain, numbness, tingling, swelling, or muscle weakness), contracture, muscle weakness, abnormalities of gait (walking) and mobility. During a review of Resident 30's Minimum Data Set (MDS-a resident assessment tool used to identify resident cognitive [pertaining to reasoning memory and judgement] and physical functional level) assessment, dated 2/17/23, the MDS indicated Resident 30's Brief Interview for Mental Status (BIMS- screening tool used in nursing home to assess cognition) assessment score was 11 out of 15 (0-15 scale [0-6 severe cognitive deficit, 7-12 moderate cognitive deficit, 13-15 no cognitive deficit]) which indicated Resident 30 had a moderate cognitive deficit. During an observation on 5/1/23, at 10:45 a.m., in Resident 30's room, Resident 30 was lying in bed, and eating a pudding using her right hand. A hand splint was on her nightstand and a sign on the wall which indicated, Please put my resting hand splint on in the morning. Wear schedule up to 8 hours, discontinue splint if she shows any signs of skin breakdown, irritation, or pain and notify OT [Occupational Therapist]. Resident 30 stated, they never put the splint on me. Resident 30 pulled her blanket back and exposed her left hand which was significantly contracted. Resident 30 stated, she had a stroke and was unable to move her fingers. During an observation on 5/2/23, at 11:24 a.m., in Resident 30's room, Resident 30's hand splint was on top of the nightstand. Resident 30 was lying in bed and pulled up her left hand to show she did not have her hand splint on. Resident 30's left hand the thumb was fully contracted into the palm of her hand, the index and second finger were stiff with moderate contractures, the ring finger and pinkie had significant contractures and was unable to straighten any of her fingers. During a concurrent observation and interview on 5/3/23, at 9:29 a.m., Resident 30 did not have the hand splint on. Resident 30 stated, some CNAs [Certified Nursing Assistants] don't want to put it on because some CNA 's can't figure it out. Resident 30 stated, the CNAs remember to put her splint on about twice per week. Resident 30 stated, she wanted to wear the splint because she did not want her hand contractures to get worse. During a concurrent observation and interview on 5/3/23, at 11:20 a.m., with CNA 5, CNA 5 stated, she was the CNA assigned to Resident 30 and was not aware Resident 30 had a splint to her left hand. CNA 5 walked inside Resident 30's room, looked at the sign above the nightstand and stated, which indicated Please put my resting hand splint on in the morning. Wear schedule up to 8 hours, discontinue splint if she shows any signs of skin breakdown, irritation, or pain and notify OT CNA 5 stated, I have never seen that sign before. CNA 5 looked through the nightstand drawers and took the hand splint out of the second drawer. CNA 5 attempted to put the splint on Resident 30's left hand but was unable to figure out how to put it on correctly. CNA 5 stated, I have never put that [hand splint] on her before. During an interview on 5/3/23, at 11:35 a.m., with Licensed Vocational Nurse (LVN) 5, LVN 5 stated resident 30 was supposed to wear the splint 5 days per week. LVN 5 stated there was a note on Resident 30's wall from therapy to remind the staff to apply the splint on Resident 30's left hand in the morning. During a concurrent interview and record review on 5/3/23, at 2:15 p.m., with LVN 5, Resident 30's physician orders titled Order Summary Report, dated 5/2023 were reviewed. Resident 30's physician orders indicated, .Resident to wear left resting hand splint for 8 hours per day, while awake, as contracture management. please check for skin impairment and inform COTA [Certified Occupational Therapy Assistant] if changes occur . LVN 5 stated, the physician order for Resident 30's hand splint to be worn for 8 hours daily was started on 2/28/23 and nursing staff did not apply the hand splint to Resident 30's left hand according to physician's order. During a concurrent interview and record review on 5/3/23, at 2:20 p.m., with the Director of Nursing (DON), Resident 30's Medication Administration Record (MAR) and Treatment Administration Record (TAR) was reviewed. The DON was not able to find documentation of Resident 30's hand splint application and monitoring. The DON stated, Resident 30's hand splint application and monitoring should be documented in the MAR and TAR. During a concurrent interview and record review on 5/4/23, at 10:06 a.m., with the Director of Rehabilitation Services (DOR), the DOR stated Resident 30 was supposed to wear a left-hand splint three to five times per week to prevent Resident 30's hand contracture from worsening which could lead to decreased mobility. Resident 30's physician orders were reviewed. The DOR stated, the physician's orders indicated Resident 30's left hand splint to be worn for 8 hours every day and was not followed. During a concurrent interview and record review on 5/8/23, at 1:35 p.m., with the DON, Resident 30's physician orders were reviewed. The DON stated, the physician's orders indicated Resident 30's left hand splint to be worn for 8 hours every day. The DON stated, the licensed nurse's responsibility was to ensure Resident 30's hand splint was applied according to physician's order and to assessed for skin breakdown underneath the splint. The DON stated Resident 30 had a history of a stroke (interruption of blood flow to the brain causing damage to brain tissue) and had contractures to the left hand and fingers. The DON stated, the physician's order for Resident 30's hand splint was not followed. The DON stated, it was important to follow the physician's orders for Resident 30's hand splint to prevent Resident 30's hand contractures from worsening which could lead to decreased in range of motion. During a review of the facility's policy and procedure (P&P) titled Provision of Physician Ordered Services, dated 10/2022, the P&P indicated, .The purpose of this policy is to provide a reliable process for the proper and consistent provision of physician ordered services according to professional standards of quality . Professional Standards of Quality means that care and services are provided according to accepted standards of clinical practice. Standards may apply to care provided by a particular clinical discipline of in a specific clinical situation or setting . 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 . Failure to formulate or follow the nursing care plan .

Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals (a substance such as vaccines or drugs derived from a living organism used for treatment) were labeled in accordance with accepted professional standards of practice for five of 23 sampled residents (Resident 1, Resident 5, Resident 15, Resident 18 and Resident 21) when: 1. Resident 5's linaclotide (a medication used to treat irritable bowel syndrome [an intestinal disorder causing pain in the belly, gas, diarrhea, and constipation] with constipation) with an expired date of 1/23/23 was stored in Medication Cart 1 ready for residents used. 2. Resident 15's insulin glargine open date and use by date was incomplete and did not indicate the year. Resident 15's medication Phenylephrine-Cocoa Butter (a medication used to temporarily relieve swelling burning, pain and itching caused by hemorrhoids [a swollen vein or group of veins in the region of the anus]) with an expired date of 4/23/23 was stored in Medication Cart 1 ready for residents used. These failure had the potential for Resident 5 and Resident 15 to receive expired medications which could lead to compromised therapeutic effectiveness and adverse reactions from expired medications. 3. Resident 1's and Resident 18's opened insulin glargine (a medication used to control the amount of glucose in the blood of persons with diabetes [a disease characterized by elevated blood sugar]) with no use by date (the last date recommended for the use of the product while at peak quality) was stored in Medication Cart 2 ready for residents use. This failure placed Resident 1 and Resident 18 at risk to receive insulin which had lost potency and not at its maximum efficacy which could lead to ineffective control of blood sugar. 4. Resident 21's fluticasone propionate/salmeterol (a medication used to treat difficulty breathing, wheezing, shortness of breath, coughing, and chest tightness caused by asthma (a disease that affects the lungs) with an expired date of 4/27/23 was stored in Medication cart 2 ready for residents use. This failure had the potential for Resident 21 to receive expired medications which could lead to compromised therapeutic effectiveness and adverse reactions from expired medications. Findings: 1. During a concurrent observation and interview on 5/2/23, at 10:02 a.m., with Licensed Vocational Nurse (LVN) 6, in the hallway, Resident 5's linaclotide with an expiration date of 1/23/23 was stored in Medication cart 1 ready for residents use. LVN 6 stated, Resident 5's linaclotide was expired on 1/23/23 and should have been removed from the medication and disposed. LVN 6 stated, the process at the facility was to discard expired medications to prevent the administration of expired and ineffective medications. During a review of Resident 5's admission Record (AR- is a document that gives a patient's information at a quick glance which includes contact details, a brief medical history and the patient's level of functioning, along with patient preferences and wishes) dated 5/2/23, the AR indicated Resident 5 had a of diagnoses of constipation. During a review of Resident 5's Order Summary Report (OSR- Physician orders) dated 5/2/23, the OSR indicated Resident 5 had no active physician's order for linaclotide. 2. During a concurrent observation and interview on 5/2/23, at 10:08 a.m., with Licensed Vocational Nurse (LVN) 6, in the hallway, Resident 15's Phenylephrine-Cocoa Butter with an expiration date of 4/23/23 was stored in Medication cart 1 ready for residents use. LVN 6 stated, Resident 15's medication Phenylephrine-Cocoa Butter was expired should have been removed from the medication cart and disposed. Resident 15's insulin glargine stored in Medication cart 1 had an open date of 4/24 and a use by date of 5/22 without an indicated year. LVN 6 stated, the process at the facility was to date the medications with the month, day and year once open. LVN 6 stated, Resident 15's insulin glargine did not indicate a year on the open and use by date. LVN 6 stated, it was important to document the month, day and year to know when to dispose the medication and to prevent the administration of expired and less effective medication. During a review of Resident 15's AR, dated 5/2/23, the AR indicated Resident 15 had a diagnoses which includes Type 2 Diabetes Mellitus (a disease characterized by an elevated blood sugar level) and constipation. During a review of Resident 15's OSR dated 5/2/23, the OSR indicated Resident 15 had medication physician orders for .100 UNIT/ML (Insulin Glargine) Inject 25 unit subcutaneously at bedtime related to TYPE 2 DIABETES MELLITUS . and . (Phenylephrine-Cocoa Butter) Insert 1 suppository rectally as needed for Hemorrhoids . 3. During a concurrent observation and interview on 5/2/23, at 10:37 a.m., with LVN 1, in the hallway, Resident 1's insulin glargine had an open date of 4/27/23 and without a use by date and Resident 18's insulin glargine had an open date of 4/27/23 and without a use by date was stored in Medication cart 2 ready for residents used. LVN 1 stated Resident 1's and Resident 18's insulin glargine should have a use by date. LVN 1 stated, the process at the facility was to document an open date and a used by date once the medications was opened. LVN 1 stated, it was the responsibility of the license nurse who opened the insulin to document the open and use by date. During a review of Resident 1's AR, dated 5/2/23, the AR indicated, Resident 1 had a diagnosis of Type 2 Diabetes Mellitus. During a review of Resident 1's OSR, dated 5/2/23, the OSR indicated, Resident 1 had a medication order for .100/UNIT/ML [milliliter] (Insulin Glargine) Inject 18 unit subcutaneously [applied under the skin] one time a day related to TYPE 2 DIABETES MELLITUS . During a review of Resident 18's AR dated 5/2/23, the AR indicated, Resident 18 had a diagnosis of Type 2 Diabetes Mellitus. During a review of Resident 18's OSR, dated 5/2/23, the OSR Indicated Resident 18 had a medication order for .100/UNIT/ML (Insulin Glargine) Inject 15 unit subcutaneously two times a day related to TYPE 2 DIABETES MELLITUS . 4. During a concurrent observation and interview on 5/2/23, at 10:45 a.m., with LVN 1, in the hallway, Resident 21's fluticasone propionate/salmeterol had an open date of 3/28/23, without a use by date and was stored in Medication cart 2 ready for residents use. LVN 1 stated, Resident 21's fluticasone propionate/salmeterol should be disposed after 30 days from the time it was opened. LVN 1 stated, the fluticasone propionate/salmeterol use by date was 4/27/23 and should have been disposed to prevent license nurse from administering expired and ineffective medications to Resident 21. During a review of Resident 21's AR, dated 5/2/23, the AR indicated, Resident 21 had a diagnoses of Respiratory Failure (a serious condition that makes it difficult to breathe on your own) and Chronic Obstructive Pulmonary Disease (a condition involving constriction of the airways and difficulty or discomfort in breathing) During a review of Resident 21's OSR, dated 5/2/23, the OSR indicated Resident 21 had a medication order for .100-50 [Microgram]/DOSE (fluticasone-Salmeterol) 1 inhalation inhale orally two times a day related to CHRONIC OBSTRUCTIVE PULMONARY DISEASE . During an interview on 5/4/23, at 11:12 a.m., with the Director of Nursing (DON), the DON stated, the process for labeling medications at the facility was for the LNs' to document the open date and use by date, so the LNs' would know when to dispose the medications. The DON stated the process at the facility was to destroy expired medications. The DON stated expired medications should not be in the Medication carts. The DON stated it was important to disposed expired medications to prevent LNs' from administering expired medications to residents. The DON stated expired medications administered to residents had the potential to lose its therapeutic efficacy which could lead to lack of treatment of symptoms for which the drug was prescribed. During a review of Medication Storage, dated 1/2021, the Medication Storage indicated, .Medications and biologicals are stored properly, following manufacturer's or provider pharmacy recommendations, to maintain their integrity and to support safe effective drug administration . Insulin products . Note the date on the label for insulin vials and pens when first used . Outdated, contaminated, discontinued or deteriorated medications . are immediately removed from stock, disposed of according to procedures for medication disposal .

**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, accurately documented in accordance with accepted professional standards of practice for one of eight sampled residents (Resident 26) when Resident 26's Physician Order for Life Sustaining Treatment (POLST-a specific medical orders for resident treatment and wishes in the case of a medical emergency) for Do Not Resuscitate (DNR- is a medical order written by a doctor which instructs health care providers not to do resuscitation [the action of reviving someone from unconsciousness or apparent death] if a patient's breathing stops or if the patient's heart stops beating) was not signed. This failure had the potential risk for Resident 26's decisions regarding his healthcare and treatment options not being honored. Findings: During a review of Resident 26's admission Record (AR- is a document that gives a patient's information at a quick glance which includes contact details, a brief medical history and the patient's level of functioning, along with patient preferences and wishes), dated [DATE], the AR indicated Resident 26 was admitted on [DATE] with diagnoses of Schizophrenia (a disorder that affects a person's ability to think, feel and behave clearly) , Major Depressive Disorder (a mental condition characterized by a persistently depressed mood and long-term loss of pleasure or interest in life), and Dysphagia (difficulty swallowing) following Cerebrovascular Disease (a group of conditions that affect blood flow and the vessels in the brain). During a review of Resident 26's Minimum Data Set (MDS- a standardized assessment and for facilitating care management in a nursing home) C, dated [DATE], the MDS indicated, Resident 26 had a Brief Interview for Mental Status (BIMS-assessment of cognitive status for memory and judgement) assessment score of 11 (a score of 13-15 indicates cognitively intact, 8-12 indicates moderate impairment, and 0-7 indicates sever impairment) indicating Resident 26 had moderate impairment. During a review of Resident 26's Order Summary Report (OSR), dated [DATE], the OSR indicated, Resident 26 had an order for DNR/Comfort Care. During a concurrent interview and record review, on [DATE] at 3:51 p.m., with the Director of Staff Development (DSD) Resident 26's POLST, dated [DATE] was reviewed. The POLST indicated, . (CPR - Cardiopulmonary Resuscitation a medical technique for reviving someone whose heart has stopped beating by pressing on their chest and breathing into their mouth): If patient has no pulse and is not breathing, if patient is NOT in cardiopulmonary arrest, follow orders . [checked box] Do Not Attempt Resuscitation/DNR (Allow Natural Death) . INFORMATION AND SIGNATURES: .Signature of Patient or Legally Recognized Decisionmaker . Print Name: [blank area] . Signature: (required) [blank area] . Date: [blank area] . The DSD stated, Resident 26's POLST was not signed by Resident 26 or his Decision-maker (DM- someone who makes decisions for another person) and was incomplete. The DSD stated, the facility's practice was for the admission nurse to ensure the POLST form was signed and completed within 72 hours from admission. The DSD stated, the incomplete POLST placed Resident 26 at risk to received treatments against his wishes. During a concurrent interview and record review, on [DATE] at 8:28 a.m., with the Director of Medical Records (DMR), Resident 26's POLST, dated [DATE] was reviewed. Resident 26's POLST did have a signature of Resident 26 or his DM and was incomplete. THE DMR stated, Resident 26's POLST should have been signed and completed. During an interview on [DATE], at 11:00 a.m., with the Director of Nursing (DON), the DON stated, Resident 26's POLST for DNR was not signed and was incomplete. The DON stated, the incomplete POLST would make Resident 26 a Full Code (if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive) and placed Resident 26 at risk to received treatments against his wishes. During a professional reference review retrieved from https://emsa.ca.gov/dnr_and_polst_forms/, titled DNR and POLST Forms, dated 2023, indicated, .The Physician's Order for Life Sustaining Treatment (POLST) form is approved by the Emergency Medical Services Authority (EMSA) and the Commission on EMS, and developed by the Coalition for Compassionate Care of California. The POLST form is a medical order that gives seriously ill patients more control over their care by specifying the type of medical treatment a patient wishes to receive at the end of life. The EMSA approved POLST form must be signed and dated by a physician, or a nurse practitioner or a physician assistant acting under the supervision of the physician, and the patient or legally recognized health care decisionmaker. The POLST form should be clearly posted or maintained near the patient . 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 .

Based on observation, interview, and record review, the facility failed to maintain an effective infection control and prevention program when one of two sampled residents (Resident 29) nasal cannula (a device used to deliver supplemental oxygen or increase airflow through the nose to a person in need of respiratory help) was on the floor and not stored inside a plastic bag. This failure placed Resident 29 at risk for cross-contamination (the physical transfer of harmful germs from person, object or place to another) and to developed respiratory infection (when germs enter the body, usually through the mouth or nose) from using contaminated nasal cannula. Findings: During a review of Resident 29's admission Record(AR- is a document that gives a patient's information at a quick glance which includes contact details, a brief medical history and the patient's level of functioning, along with patient preferences and wishes), dated 5/2/23, the AR indicated, Resident 29 had the diagnoses of Chronic Obstructive Pulmonary Disease (a condition involving constriction of the airways and difficulty or discomfort in breathing) and Acute and Chronic Respiratory Failure (a condition in which your blood doesn't have enough oxygen or has too much carbon dioxide) with Hypoxia (am absence of enough oxygen in the tissues to sustain bodily functions). During a review of Resident 29's Medication Profile (MP), dated 2/6/23, the MP indicated, Oxygen Intranasal -Both Nostrils 2 [liters- unit of measurement] Continuous . During an observation on 5/1/23, at 10:42 a.m., in Resident 29's room, Resident 29's nasal cannula was attached to an oxygen concentrator (medical device that gives extra oxygen) on the floor without a plastic bag cover. During a concurrent observation and interview on 5/1/23, at 11:10 a.m., with Licensed Vocational Nurse (LVN) 2, Resident 29's room, LVN 2 stated, Resident 29's nasal cannula was on the floor, not stored inside a plastic bag and should be disposed. LVN 2 stated, the facility process was for Resident 29's nasal cannula when not in used should be stored inside a plastic bag and off the floor to prevent cross contamination. LVN 2 stated, there was no plastic bag available to store Resident 29's nasal cannula. LVN 2 stated, there was a potential risk for Resident 29 to be infected with germs from the floor to his nose by way of using contaminated nasal cannula. During an interview on 5/4/23, at 10:42 a.m., with the Infection Preventionist (IP), the IP stated, the facility process for nasal cannula when not in use should be stored inside a plastic bag and off the floor to keep the nasal cannula clean, sanitary and prevent cross contamination. The IP stated there was a potential risk for Resident 29 to developed respiratory infection from using contaminated nasal cannula. During a concurrent interview and record review on 5/23/23, at 10:52 a.m., with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Oxygen Administration, (undated), the P&P indicated, . Policy Explanation and Compliance Guidelines . Change oxygen tubing . as needed if it becomes soiled or contaminated . Keep delivery devices covered in plastic bag when not in use . The DON stated it was important for Resident 29's nasal cannula when not in used to be stored inside a plastic bag and off the floor to prevent cross- contamination which could lead to respiratory infection. The DON stated the facility's P&P was not followed. During a professional reference review retrieved from https://www.cdc.gov/infectioncontrol/spread/index.html, titled How Infections Spread, dated January 7, 2016, indicated, .An infection occurs when germs enter the body, increase in number, and cause a reaction of the body. Three things are necessary for an infection to occur: Source: Places where infectious agents (germs) live (e.g., sinks, surfaces, human skin) Susceptible Person with a way for germs to enter the body Transmission: a way germs are moved to the susceptible person . Transmission refers to the way germs are moved to the susceptible person . Germs don't move themselves. Germs depend on people, the environment, and/or medical equipment to move in healthcare settings. A Source is an infectious agent or germ and refers to a virus, bacteria, or other microbe. In healthcare settings, germs are found in many places. People are one source of germs including . Germs are also found in the healthcare environment. Examples of environmental sources of germs include: Dry surfaces in patient care areas (e.g., bed rails, medical equipment, countertops, and tables) Wet surfaces, moist environments, and biofilms (e.g., cooling towers, faucets and sinks, and equipment such as ventilators) .

Based on observation and interview, during the survey period of 5/1/23 to 5/8/23, the facility failed to provide the minimum of at least 80 square feet per resident in 10 out of 17 rooms (Rooms 1, 2, 5, 6, 11, 12, 14, 15, 16 and 17). This failure had the potential for residents to not have reasonable accommodations for privacy or adequate space for care to be rendered. Findings: During a concurrent observation and interview with the Director of Maintenance (DOM) and Housekeeping Supervisor on 5/4/23, at 10:58 a.m., the DOM stated he was aware ten rooms did not meet the minimum square footage required. The room measurements were as follows: Room # Square Feet Number of residents 1 156.18 2 2 157.20 2 5 215.68 3 6 214.27 3 11 216.02 3 12 216.56 3 14 217.96 3 15 156.83 2 16 156.96 2 17 157.20 2 During multiple observations made between 5/3/23 to 5/8/23, and the residents had a reasonable amount of privacy. The residents had closets and bedside tables which provided adequate storage space. There was sufficient room for nursing care and for residents to ambulate. Wheelchairs and toilet facilities were accessible. The waiver will not adversely affect the health and safety of residents. Recommend room waiver remain in effect. _____________________________________ HFES Signature Date Request waiver continue in effect. ____________________________________ Facility Administrator Signature Date

Based on observation, interview and record review, the facility failed to ensure food service staff were able to carry out the functions of the food and nutrition service safely and effectively when Kitchen staff (CKA 1, CKA 2, and KA 1) did not air dry bowls and cups prior to storage, did not label opened food products with use by date, did not place a drip pan on thawed uncooked frozen meat inside the refrigerator, and did not perform appropriate glove use in the kitchen. Failure to have staff with the appropriate competencies and skill sets to carry out the functions of food and nutrition services can result in foodborne illnesses from cross contamination or the growth of microorganisms for the 44 residents eating food prepared in the facility. (Cross Reference F812) Findings: During a concurrent observation on 5/1/23, at 9:15 a.m., inside the kitchen, with Cook/Kitchen Aide (CKA), CKA 1 placed a tray of wet bowls inside the cabinet. CKA 1 lifted the bowls and water dripped from the bowls, and stated, the bowls were wet. During a concurrent observation and interview on 5/1/23, at 9:52 a.m., in the kitchen with Kitchen Aide (KA) 1, opened and unsealed box of cereal was stored in the dry food storage room without an open date and a use by date. KA 1 stated, the opened cereal should have been sealed to prevent insects and bugs from entering the cereal container and have a use by date. During a concurrent observation and interview on 5/1/23, at 10:05 a.m., in the kitchen with CKA 1, uncooked frozen chicken thighs inside a cardboard box were thawed on the bottom of the refrigerator without a drip pan underneath. CKA 1 stated, there was no room in the freezer, so she placed the uncooked frozen chicken thighs inside the refrigerator. CKA 1 stated, the uncooked chicken thighs should have been placed in a pan, but she had no time to placed them in the pan. During a concurrent interview and record review on 5/1/23, at 10:10 a.m., inside the kitchen, with CKA 1, CKA 1 stacked wet cups inside cabinet. CKA 1 stated, the cups were wet. During a concurrent interview and record review on 5/1/23, at 3:07 p.m., with the Resgistered Dietitian (RD), the RD reviewed Nutrition Services Monthly Sanitation Report (NSMSR), dated 4/28/23, the RD stated, the NSMSR of the kitchen did not include checking for dishware stored wet. During an interview on 5/1/23, at 3:21 p.m., the RD stated, the opened cereal should have been sealed to prevent bugs from entering the cereal container and have a use by date. The RD stated, the opened and unsealed cereal placed residents at high risk for cross contamination which could lead to foodborne illness. The RD stated, food items should not be placed inside a cardboard box and stored in the refrigerator to prevent cross contamination which could lead to foodborne illness. During a concurrent observation and interview on 5/2/23, at 10:57 a.m., CKA 1 handled the recipe binder with a gloved hand and immediately handled food serving scoop without removing his gloves, performing hand hygiene, and putting on new gloves. CKA 1 stated, after handling the recipe binder she should have removed her gloves, performed hand hygiene, put on new gloves before handling the food serving scoop to prevent cross contamination. During a concurrent observation and interview on 5/2/23, at 11:23 a.m., with CK 2, in the kitchen, CKA 2 was making pudding without the use of gloves. CKA 2 stated, she should have worn gloves when preparing food. During a concurrent interview and record review on 5/3/23, at 10:44 a.m., with the Administrator (ADM), CKA 1, CKA 2, and KA 1 Employee File (EF) was reviewed. the ADM stated, CKA 1, CKA 2, and KA 1 did not have competencies for food safety handling. The ADM stated, . if that's what needs to be corrected, then that's what needs to be corrected . During a concurrent interview and record review on 5/4/23, at 1:45 p.m., with the Certfiied Dietary Manager (CDM), CKA 1's EF was reviewed. The CDM stated, there was no kitchen orientation for food safety handling documented for CKA 1. During a concurrent interview and record review on 5/4/23, at 1:47 p.m., with the CDM, KA 1's EF was reviewed. The CDM stated, there was no kitchen orientation for food safety handling documented for KA 1. According to the Food and Drug Administration (FDA) Food Code 2017, Section 4-901.11 Equipment and Utensils, Air-Drying Required, After cleaning and sanitizing, equipment and utensils: (A) Shall be air-dried or used after adequate draining . before contact with food. During a review of a professional reference, titled Can you stack wet dishes after you washed them?, dated 12/7/22, retrieved from https://mydelicioussweets.com/can-you-stack-wet-dishes-after-you-washed-them/, indicated, . It is not good practice to store wet dishes, as remaining moisture will promote the growth of microorganisms on the surface of the items and in kitchen cabinets . Review of a Food Service In-service titled Labeling and Dating Food Products dated 7/30/2019 showed It is important to label ALL items in your kitchen with product name, received date, and open date. It is important to label and date, as it: Prevents food-borne illness caused from spoiled foods Prevents wasting of food .Prevents staff from using the wrong ingredient. All items must be labeled with the food product name. Dates should include the month, day and year. Count the day the product was opened or made as day 1. During a review of a professional reference, titled State Operations Manual (SOM), dated 2/3/23, the SOM indicated, . Safe Food Preparation . to reduce cross-contamination . Store raw meat separately and in drip-proof containers and in a manner that prevents cross-contamination of other food in the refrigerator . methods to safely thaw frozen foods . During a review of a professional reference, titled, Are cardboard boxes bad for food safety in the kitchen?, dated 2023, retrieved from https://hygienefoodsafety.org/why-are-cardboard-boxes-bad-for-food-safety-in-the-kitchen/, indicated, . cardboard boxes in food safety .are not safe for usage and for storage of foods in a kitchen . boxes come in contact with areas that are dirty . the kitchen does not know how and in what conditions the boxes were kept . Pests have been known to lay eggs in the corrugated areas of boxes (spaces between the boards meant for insulation) . Harmful bacteria are able to survive on wet cardboard which encourages cross-contamination . During a review of a professional reference, titled State Operations Manual (SOM), dated 2/3/23, the SOM indicated, . Safe Food Preparation . to reduce cross-contamination . Store raw meat separately and in drip-proof containers and in a manner that prevents cross-contamination of other food in the refrigerator . methods to safely thaw frozen foods . During a review of a professional reference, the SOM, the SOM indicated, . Employees should never use bare hand contact with any foods . the skin carries microorganisms, it is critical that staff involved in food preparation, distribution and serving consistently utilize good hygiene practices . gloved hands are considered a food contact surface that can get contaminated or soiled. Disposable gloves are a single use item and should be discarded between and after each use . Hands must be washed before putting on gloves and after removing gloves . According to the 2017 Food and Drug Administration (FDA) Food Code, Section 2-301.14 states: Food employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles and: .After touching bare human body parts other than clean hands and clean, exposed portions of arms; . During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; .Before donning gloves to initiate a task that involves working with food; .and after engaging in other activities that contaminate the hands.

Based on observations, interviews and record review, the facility failed to ensure professional standards for food safety guidelines were followed when, 1. Cake stored inside the kitchen refrigerator was not fully covered and placed on top of a torn cardboard boxes with moisture stains. 2. Cheese slices and whipped cream were placed inside unsealed plastic bags stored inside the kitchen refrigerator. 3. Wet bowls and cups were stacked and stored inside the cabinet. 4. Cooking spices were stored unsealed and in containers with debris. 5. Opened bag of frozen sausage patties was in the freezer without an opened date. 6. Five meal tray carts were stored in the kitchen storage room with 44 uncovered meal trays, and a bag of plastic forks placed on the top of a plate, more than two hours before meal service. 7. The kitchen backdoor was fully open without a closed-door screen during food preparation. 8. Uncooked frozen chicken thighs inside a cardboard box was thawed in the bottom of the refrigerator without a drip pan (a pan placed underneath thawed frozen food to catch the drippings and prevent food contamination) underneath. 9. Opened and unsealed box of cereal was stored in the dry food storage room without an open date and a use by date. 10. Glue traps were found with dust, debris, and a dead cockroach on the dry food storeroom. 11. The floors and baseboards in the kitchen, kitchen storage room, and dry food storage room had chips, cracks, and gaps with debris. 12. Cleaning chemicals were stored on the kitchen floor next to food preparation sink. 13. Kitchen Aide (KA) 1's personal backpack was stored on the floor in kitchen storage room. 14. The Kitchen walls and windowsills had peeled paint and windowsills had dead insects, dust and debris above the food preparation sink, dish washing, and dish drying areas. 15. The foot pedal on the kitchen waste bin was broken and required staff to use their hands to open. 16. The gas line to stove had a gray- green substance. 17. Kitchen Cooks did not demonstrate proper glove use and hand hygiene. These failures had the potential to cause foodborne illnesses in a medically vulnerable resident population of 44 residents who consumed food prepared in the kitchen. Findings: 1. During an observation on 5/1/23, at 9:12 a.m. in the kitchen, a cake stored inside the refrigerator was partially covered with foil and was placed on top of torn cardboard boxes with moisture stains. During a concurrent interview and record review on 5/1/23, at 3:04 p.m., with the Registered Dietitian (RD), photos taken on 5/1/23 of partially covered cake and cardboard boxes stored inside the kitchen refrigerator were reviewed. The RD stated, the cake should have been completely covered, and cardboard boxes should not be stored inside the refrigerator to prevent bug infestation and cross-contamination of food. During a review of a professional reference, titled, Are cardboard boxes bad for food safety in the kitchen?, dated 2023, retrieved from https://hygienefoodsafety.org/why-are-cardboard-boxes-bad-for-food-safety-in-the-kitchen/, indicated, . cardboard boxes in food safety .are not safe for usage and for storage of foods in a kitchen . boxes come in contact with areas that are dirty . the kitchen does not know how and in what conditions the boxes were kept . Pests have been known to lay eggs in the corrugated areas of boxes (spaces between the boards meant for insulation) . Harmful bacteria are able to survive on wet cardboard which encourages cross-contamination . 2. During an observation on 5/1/23, at 9:13 a.m., in the kitchen, cheese slices and whipped cream were placed inside unsealed plastic bags stored inside the refrigerator. During a concurrent interview and record review on 5/1/23, at 3:05 p.m., with the RD, photos taken on 5/1/23 of cheese slices and whipped cream placed inside unsealed plastic bag were reviewed. The RD stated, the plastic bags containing food items should have been resealed every time it was used. During a concurrent interview and record review on 5/1/23, at 5:47 p.m., with the Administrator (ADM), the photos taken 5/1/23 of cheese slices and whipped cream stored inside unsealed plastic bags were reviewed. The ADM stated, the plastic bags should have been properly sealed to maintain food quality and to prevent from drying out. During a review of Dietary In- Service (DIS), dated 5/1/23, indicated a 1:1 in-service was presented by the RD. The DIS indicate the subject of the in-service was . Food must be properly sealed when stored. Use Gallon storage bags, label & seal completely. Boxes will be eliminated as much as possible when storing food in refrigerator . During a review of a professional reference, titled Toss it? Top tips for keeping food fresh and safe, dated 2023, retrieved from https://www.today.com/food/toss-it-top-tips-keeping-food-fresh-safe-wbna17472632, indicated, . Never put uncovered foods in your refrigerator . you cannot see, taste or smell bacteria until it's too late and can cause serious food illnesses . 3. During a concurrent observation on 5/1/23, at 9:15 a.m., inside the kitchen, with Cook/Kitchen Aide (CKA), CKA 1 placed a tray of wet bowls inside the cabinet. CKA 1 lifted the bowls and water dripped from the bowls, and stated, the bowls were wet. During a concurrent interview and record review on 5/1/23, at 10:10 a.m., inside the kitchen, with CKA 1, CKA 1 stacked wet cups inside cabinet. CKA 1 stated, the cups were wet. During a concurrent interview and record review on 5/1/23, at 3:07 p.m., with the RD, the RD reviewed Nutrition Services Monthly Sanitation Report (NSMSR), dated 4/28/23, the RD stated, the NSMSR of the kitchen did not include checking for dishware stored wet. According to the Food and Drug Administration (FDA) Food Code 2017, Section 4-901.11 Equipment and Utensils, Air-Drying Required, After cleaning and sanitizing, equipment and utensils: (A) Shall be air-dried or used after adequate draining . before contact with food. During a review of a professional reference, titled Can you stack wet dishes after you washed them?, dated 12/7/22, retrieved from https://mydelicioussweets.com/can-you-stack-wet-dishes-after-you-washed-them/, indicated, . It is not good practice to store wet dishes, as remaining moisture will promote the growth of microorganisms on the surface of the items and in kitchen cabinets . 4. During an observation on 5/1/23, at 9:13 a.m., in the kitchen, six spice containers were unsealed with debris on the containers. During a concurrent interview and record review on 5/1/23, at 5:20 p.m., with the RD, photos taken on 5/1/23 of spices stores in unsealed containers with visible debris and the NSMSRs, the NSMSR dated 3/27/23 and 4/28/23, were reviewed. The RD stated, both NSMSRs indicated, the spice containers were not sealed and clean. The RD stated, the NSMSRs was sent to the Certified Dietary Manager (CDM) and the ADM but had not discussed the issue with the CDM. The RD stated, the unsealed and dirty spice containers was not addressed by the CDM. The RD stated, the expectations was for the CDM to addressed the issues once it was brought up to her attention. The RD stated, if the issues continued for more than two months, she would escalate the issue to the ADM. The RD stated she had not escalated the issue to the ADM. During a concurrent interview and record review on 5/1/23, at 5:48 p.m., with the ADM, the NSMSRs, dated 3/27/23 and 4/28/23, were reviewed. The ADM stated, he expected the RD and CDM to notify him for continued issues in the kitchen. The ADM stated, the RD and the CDM did not notify him, and perform intervention to address the issues identified on the NSMRS. The ADM stated, residents' immune systems were vulnerable and at risk for foodborne illnesses when kitchens are not kept clean and sanitary. During a concurrent interview and record review on 5/4/23, at1:50 p.m., with the CDM, the NSMSRs, dated 10/26/22, 11/30/22, 1/30/23, 3/27/23, and 4/28/23 were reviewed. The CDM stated, all the NSMSRs indicated, the spice containers were unsealed and not clean. 5. During a concurrent observation and interview on 5/1/23, at 10:20 p.m., in the kitchen with CKA 1, opened sausage patties were in the freezer without an open date and a used by date. CKA 1 stated the patties should have an opened date and a use by date to show when they should be used. During an interview on 5/1/23, at 3:10 p.m., with the RD, the RD stated open frozen foods needed to have a use by date on the package. During a review of a professional reference, titled How long does food last in the freezer?, dated 5/4/19, retrieved from https://www.highspeedtraining.co.uk/hub/how-long-can-you-store-frozen-food-for/#:~:text=Food%20can%20remain%20frozen%20indefinitely,to%20happen%20varies%20between%20foods, indicated, . over time all frozen food will deteriorate in quality . keep frozen cooked meat for no longer than three to six months . 6. During a concurrent observation and interview on 5/1/23, at 10:00 a.m., with KA 1, in the kitchen, two meal carts were stored next to the kitchen stove and three meal carts were stored in the kitchen storage room. Each of the five meal carts had 44 meal trays. The meal trays did not have a cover and plastic forks had fallen on top of the meal trays. KA 1 stated, the meal trays were always stored in the meal cart two hours or more prior to meal service. During a review of Meal Service Times (MST), (undated), the MST indicated, breakfast was served from 7:00 a.m. to 7:15 a.m. and lunch was served from 12:00 p.m. and 12:15 p.m. During a concurrent interview and record review on 5/1/23, at 3:22 p.m., with the RD, the RD reviewed the photos taken on 5/1/23, at 10 a.m. of meal trays inside the meal carts. The RD stated meal trays prepared and placed on meal carts two hours or more prior to meal service was not the proper way. During a review of Dietary In- Service (DIS), dated 5/1/23, indicated a 1:1 in-service was presented by the RD. The DIS indicate the subject of the meeting was . Plates will not be placed on residents [sic] tray uncovered. Plates will be covered by lid or placed on base no earlier than 30 minutes before trayline [meal service] begins . 7. During an observation on 5/1/23, at 9:30 a.m., in the kitchen, the kitchen back door was fully opened, without a closed-door screen during food preparation. During an interview on 5/1/23, at 4:18 p.m., the RD stated, the kitchen back door should not be opened and should be closed during food preparation. During an interview on 5/1/23, at 5:55 p.m., the ADM stated, the kitchen back door should not be opened and should be closed to prevent pest from entering the kitchen which could lead to foodborne illness to residents. 8. During a concurrent observation and interview on 5/1/23, at 10:05 a.m., in the kitchen with CKA 1, uncooked frozen chicken thighs inside a cardboard box were thawed on the bottom of the refrigerator without a drip pan underneath. CKA 1 stated, there was no room in the freezer, so she placed the uncooked frozen chicken thighs inside the refrigerator. CKA 1 stated, the uncooked chicken thighs should have been placed in a pan, but she had no time to placed them in the pan. During an interview on 5/1/23, at 3:20 p.m., the RD stated, food items should not be placed inside a cardboard box and stored in the refrigerator to prevent cross contamination which could lead to foodborne illness. During a review of a professional reference, titled State Operations Manual (SOM), dated 2/3/23, the SOM indicated, . Safe Food Preparation . to reduce cross-contamination . Store raw meat separately and in drip-proof containers and in a manner that prevents cross-contamination of other food in the refrigerator . methods to safely thaw frozen foods . 9. During a concurrent observation and interview on 5/1/23, at 9:52 a.m., in the kitchen with KA 1, an opened and unsealed box of cereal was stored in the dry food storage room without an open date and a use by date. KA 1 stated, the opened cereal should have been sealed to prevent insects and bugs from entering the cereal container and have a use by date. During an interview on 5/1/23, at 3:21 p.m., the RD stated, the opened cereal should have been sealed to prevent bugs from entering the cereal container and have a use by date. The RD stated, the opened and unsealed cereal placed residents at high risk for cross contamination which could lead to foodborne illness. Review of a Food Service In-service titled Labeling and Dating Food Products dated 7/30/2019 showed It is important to label ALL items in your kitchen with product name, received date, and open date. It is important to label and date, as it: Prevents food-borne illness caused from spoiled foods Prevents wasting of food .Prevents staff from using the wrong ingredient. All items must be labeled with the food product name. Dates should include the month, day and year. Count the day the product was opened or made as day 1. 10. During a concurrent observation and interview on 5/1/23, at 9:53 a.m., with KA 1, in the dry food storage room, glue traps (a trap that uses glue, adhesive material as the mode of capture to trap rodents and insects) were found with a dead cockroach and dust debris. KA 1 stated, it was the first time she saw the glue trap with a dead cockroach. KA 1 stated, the glue trap with a dead cockroach should have been removed to prevent food contamination. During a concurrent interview and record review on 5/1/23, at 5:56 p.m. with the ADM, the photos taken 5/1/23, of glues traps with a dead cockroach and dust debris in the dry food storage room were reviewed. The ADM stated the expectation was for the kitchen and food storage areas to be free of pests and insects. 11. During an observation on 5/1/23, at 9:56, the linoleum floor (a water-resistant floor covering) in the kitchen, next to the back door had chips and cracks in multiple places with debris in between the cracks. During an observation on 5/1/23, at 9:50 a.m., in dry food storage room, the linoleum floor had cracks and gaps between baseboards and the gaps contained debris. During an observation on 5/1/23, at 9:59 a.m., in the kitchen storage room, the linoleum floor had large chips which shows the concrete underneath. The baseboard was separated from the wall with visible brown stains behind baseboard. During an interview on 5/1/23, at 3:24 p.m., with the RD, the RD stated, the kitchen floors have been in disrepair since she had been working in the kitchen. The RD stated, intact floors were important to prevent dirt and bugs collecting in the cracks and gaps which can cause cross-contamination. The RD stated, residents are at high risk for foodborne illnesses caused by cross-contamination. 12. During a concurrent observation and interview on 5/1/23, at 10:08 a.m., with KA 1, in the kitchen, cleaning chemical supplies were stored on the floor next to the food preparation sink. KA 1 stated, the cleaning chemicals are always stored on the floor next to the sink. During the review of a professional reference, titled State Operations Manual, dated 2/3/23, indicated, . Chemical Contamination . cleaning products and supplies, must be clearly marked as such and stored separately from food items . 13. During a concurrent observation and interview on 5/1/23, at 10:10 a.m., with KA 1, in the kitchen, KA 1's personal backpack was stored on the floor next to the refrigerator. KA 1 stated, she was not provided a locker to store her personal belongings. During an interview on 5/1/23, at 3:05 p.m., with the RD, the RD stated, kitchen staff should not store personal belongings on the kitchen floor and should have designated place to store personal belongings away from food and kitchen equipment to prevent cross contamination. 14. During an observation on 5/1/23, at 9:57 a.m., the windowsills above the food preparation sink, and behind the dishwasher had chipped paint, dust, and dead insects. During an observation on 5/1/23, at 10:22 a.m., in the kitchen, the kitchen wall and dish drying area backsplash had black debris. During a concurrent interview and record review on 5/1/23, at 5:25 p.m., with the RD, the RD reviewed the photos of kitchen walls and windowsills taken on 5/1/23 with peeled paint, dust, debris, and dead insects. The RD stated, she did a kitchen sanitation audit to make sure the staff were following policy and procedure and ensure the kitchen was sanitary. The RD declined to answer if kitchen was sanitary. During a concurrent interview and record review on 5/1/23, at 5:57 p.m. the ADM, the ADM reviewed the picture of the kitchen taken on 5/1/23 with peeled paint, dust, debris, and dead insects. The ADM stated, . I have seen enough. With the pics as presented, I would say the kitchen is not sanitary . During a concurrent observation and interview on 5/2/23, at 9:33 a.m., with the CDM, the CDM stated, the black debris on the wall and back splash were caused by the cleaning squeegee (a tool use to remove or control liquids across surfaces). The CDM demonstrated how the squeegee left black marks on his hand. During a concurrent observation and interview on 5/2/23, at 9:35 a.m., the CDM stated, the kitchen was deep cleaned every week and once a month. The CDM stated, the kitchen window above food preparation sink had dirt and dust. The CDM stated, when the window was wiped with a paper towel, a dust ball fell into sink. The CDM stated, the window was not where food was prepared and the dust . only fell in the sink because you [surveyor] wiped it off . the CDM declined to answer if the kitchen was sanitary. During a review of Dietary In- Service (DIS), dated 5/1/23, indicated a 1:1 in-service was presented by the RD. The DIS indicate the subject of the meeting was . Cleanliness of kitchen- Make sure your work area is clean & sanitized at end of each shift worked. Make sure to complete weekly & monthly cleaning schedule . 15. During a concurrent observation and interview on 5/2/23, at 9:33 a.m., the foot pedal on the waste bin was broken and the lid failed to open. The CDM attempted to open the waste bin by stepping on the foot pedal and failed to open the waste bin. The CDM stated, the waste bin foot pedal was broken. During an interview on 5/2/23, at 10:22 a.m., CKA 1 stated, the foot pedal on the waste bin was broken one or two weeks ago. CKA 1 stated, the kitchen staff had to use their hands or arms to open the waste bin. 16. During an observation on 5/2/23, at 12:21 p.m., the gas line to the stove next to the meal tray carts storage area had a green-gray substance. During a concurrent interview and record review on 5/4/23, at 1:43 p.m., with the CDM, the CDM reviewed photos taken on 5/2/23 of the gas line to the stove with green-gray substance. The CDM stated he did not know what the green-gray substance on the gas line was. 17. During a concurrent observation and interview on 5/2/23, at 10:57 a.m., CKA 1 handled the recipe binder with a gloved hand and immediately handled food serving scoop without removing his gloves, performing hand hygiene, and putting on new gloves. CKA 1 stated, after handling the recipe binder she should have removed her gloves, performed hand hygiene, put on new gloves before handling the food serving scoop to prevent cross contamination. During a concurrent observation and interview on 5/2/23, at 11:23 a.m., with CK 2, in the kitchen, CKA 2 was making pudding without the use of gloves. CKA 2 stated, she should have worn gloves when preparing food. According to the 2017 Food and Drug Administration (FDA) Food Code, Section 2-301.14 states: Food employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles and: .After touching bare human body parts other than clean hands and clean, exposed portions of arms; . During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; .Before donning gloves to initiate a task that involves working with food; .and after engaging in other activities that contaminate the hands. During a review of a professional reference, the SOM, the SOM indicated, . Employees should never use bare hand contact with any foods . the skin carries microorganisms, it is critical that staff involved in food preparation, distribution and serving consistently utilize good hygiene practices . gloved hands are considered a food contact surface that can get contaminated or soiled. Disposable gloves are a single use item and should be discarded between and after each use . Hands must be washed before putting on gloves and after removing gloves .

Based on observations, interviews, and record review, the facility failed to maintain an effective pest control program, when a dead cockroach was found on a glue trap (a trap that uses glue, adhesive material as the mode of capture to trap rodents and insects) in the food storage room and dead insects were found on the kitchen windowsills above the food preparation area and dish sink. These failures had the potential to cause foodborne illnesses (illness caused by food contaminated with bacteria, viruses, and parasites) in a medically vulnerable resident population of 44 residents who consumed food prepared in the kitchen. Findings: During an observation on 5/1/23, at 9:15 a.m., in the kitchen, the back door is fully open without a door screen while food is being prepared. During an observation on 5/1/23, at 9:42 a.m., inside the food storage room, one dead cockroach was captured in the glue trap. During a concurrent observation and interview on 5/1/23, at 9:52 a.m., in the food storage room, with the Dietary Aide (DA) 1, DA 1 stated, the cockroach should not be inside the food storage room, because it could get into the food. During an observation on 5/1/23, at 9:56 a.m., in the kitchen, the windowsills above the food preparation area and dish sink, had a dead large insect and multiple small dead insects. During a concurrent interview and record review on 5/1/23, at 3:10 p.m., with the Registered Dietitian (RD), the RD reviewed the photos of the cockroach inside the food storage room and the insects on the kitchen windowsills. The RD stated, the kitchen should have been check for pest infestation monthly as part of the monthly sanitation audit. The RD stated, she did look for dead insects in the windowsills during her sanitation audit on 4/28/23. During an interview on 5/1/23, at 4:18 p.m., the RD stated, the back door to the kitchen should have not been opened and should be closed during food preparation to prevent pest from entering the kitchen. During a concurrent interview and record review on 5/1/23, at 5:47 p.m., with the Administrator (ADM), the ADM reviewed the photos taken in the kitchen of the glue traps with a dead cockroach and dead insects on the windowsills. The ADM stated the expectation was for the kitchen and food storage areas to be free of pests and insects. During a review of a professional reference, titled California Code of Regulations (CCR), (undated), retrieved from, https://govt.westlaw.com/calregs/Document/IB97EE82C5B6111EC9451000D3A7C4BC3?viewType=FullText&originationContext=documenttoc&transitionType=CategoryPageItem&contextData=(sc.Default), indicated, in Skilled Nursing Facilities, . All kitchens and kitchen areas shall be . protected from rodents, roaches, flies, and other insects .

Based on interview, and record review the facility failed to maintain an effective system for receiving controlled drugs (medications with potential for abuse to be accounted for by licensed nurses), for one of three sampled residents (Resident 1) when 45 oxycodone acetaminophen (OA- medication used to relieved moderate to severe pain) tablets delivered to the facility went missing. This failure had the potential for diversion (used illegally) of controlled substance medications. 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 with diagnoses which included acute pain. During a telephone interview on 6/15/22, at 9:26 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she was from registry (temporary employment through third company) and it was her first day working at the facility on 6/10/22. LVN 1 stated, during her shift a female employee from hospice (end of life care) (company name) handed her two bubble packs (sealed compartments for medication) of medication and informed her the medication was for Resident 1. LVN 1 stated she did not recall the medications, because when the medications were given to her, she was looking for the facility portable phone for a resident. LVN 1 stated she was sidetracked with her duties and left the two OA bubble pack by the computer and the bubble pack completely slipped my mind. LVN 1 stated, when she came back on shift on 6/11/22 she was informed the OA was missing. LVN 1 stated she searched the medication room, medication cart, trash bins and binders but was unable to find the two OA bubble packs. LVN 1 stated she didn ' t sign anything when the hospice nurse handed over the two OA bubble packs and stated normally controlled medications needed to be signed. LVN 1 stated it was her responsibility to know the medications she received and should have paid attention, so the medication would not go missing. LVN 1 stated no medication should ever be left unattended. During a telephone interview on 6/15/22, at 9:39 a.m., with Hospice Director of Nursing (HDON), HDON stated two OA bubble packs were sent to the facility one pack had 30 OA and the other had 15 OA ' s. HDON stated normally the pharmacy delivered the medications but on 6/10/22 we had to expedite the delivery, Hospice Licensed Vocational Nurse (HLVN) 1 delivered the medication to the facility. HDON stated the medication was picked up from the pharmacy and the medication manifests (list of residents' medications received by facility from pharmacy) was signed by HLVN 1 when she picked up the medication. During a telephone interview on 6/15/22, at 10:59 a.m., with HLVN 1, HLVN 1 stated, on 6/10/22 she was notified by HDON to pick up and deliver Resident 1 ' s medication. HLVN 1 stated she picked up two bubble packs one had 30 OA and the other had 15 OA medications. HLVN 1 stated she handed the medications to LVN 1 and was witnessed by LVN 2. HLVN 1 stated in normal situations pharmacy delivers medications, only in emergency situations when the facility was running low on the medications the hospice nurse delivers medications. HLVN 1 stated, on 6/11/22 she was informed by the HDON the OA medication was missing. During a telephone interview on 6/15/22, at 11:07 a.m., with LVN 2, LVN 2 stated, on 6/10/22 she was at lunch when HLVN 1 delivered medications and was unaware of the medication delivery. LVN 2 stated on 6/11/22 she was going to administer the OA when she realized there was no OA medications for Resident 1. LVN 2 stated she called and notified the HDON the two OA packs delivered on 6/10/22 was missing. LVN 2 stated they searched for the OA medications but were unable to find. During an interview on 6/15/22, at 11:40 a.m., with Pharmacy (PH), PH stated on 6/10/22 HLVN 1 picked up from pharmacy Resident 1 ' s two OA bubble pack ' s, one pack contained 30 and the other pack contained 15 which totaled to 45 OA. PH stated HLVN 1 signed the medication manifest (a document with information of the goods transported) when she picked up the medications. During a telephone interview on 6/15/22, at 11:59 a.m., with LVN 3, LVN 3 stated she was working on 6/10/22. LVN 3 stated she witnessed the exchange of two bubble packs of medication between HLVN 1 and LVN 1. LVN 3 stated she did not know the medications delivered but heard HLVN 1 stated the medications was for Resident 1. During a concurrent interview and record review on 6/15/22, at 12:30 p.m., with Director of Nursing, Resident 1 ' s Order Summary Report (OSR), dated 6/1/22 was reviewed. The OSR indicated, [brand name (OA)] Give 1 tablet by mouth three times a day related to acute pain . DON stated, when HLVN 1 handed the OA medication to LVN 1, LVN 1 should have stopped what she was doing and ensured the OA was accounted for. During a concurrent interview and record review on 6/15/22, at 12:45 p.m., with the DON, the facility policy titled Ordering and Receiving Controlled Medications dated 2007 was reviewed. The policy indicated, .medications classified as controlled substances by state law, are subject to special ordering, receipt, and record keeping requirements in the nursing care center, in accordance with federal and state laws and regulations .Medications .dispensed by the pharmacy in readily accountable quantities and containers designed for easy counting of contents .The pharmacy or the nursing care center prepares an individual resident controlled substance record/receipt/log for each controlled substance medication prescribed for a resident. This log is placed in the MAR or narcotic book to be counted every shift .The following information is completed: a. Name of resident b. Prescription number c. Medication name d. Medication strength e. Dosage form of medication f. Date received g. Quantity received h. Name of person receiving the medication supply . DON stated medications should not be left unattended it should be locked inside the med room. DON stated the purpose was to safeguard the medications from residents, staff and from getting misplaced.